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PRACTICAL Cy/^<?^^^^^^y 
 
 ON /f<^^' 
 
 THE DISEASE OF THE JOINTS, 
 
 COMMO!MLT CALLED 
 
 WHITE-SWELLING; 
 
 WITH 
 
 REMARKS ON CARIES, NECROSIS, AND SCRO- 
 FULOUS ABSCESS, 
 
 IN WHICH A NEW AND SUCCESSFUL METHOD OF TREATING 
 THESE COMPLAINTS IS POINTED OUT. 
 
 A J\EW EDITION, 
 
 WITH CONSIDERABLE ADDITIONS AND IMPROVEMENTS, ILLUSTRATED 
 
 WITH SEVEX COLOURED PLATES. 
 
 BY 
 
 BRYAN CROWTHER, 
 
 MEMBER OF THE ROYAL COLLEGE OF SORGFONS IN LONDON, AND 
 SURGEON TO BRIDE'VVELL AND BETHLEM HOSPITALS. 
 
 The operative part of Surgery is far from being the whole of it ; and I 
 cannot help thinking that, by attending a little more to what is called com- 
 mon or practical Surgery, our art might still be considerably improved, 
 practitioners rendered more expert, and mankind much benefited. — Pott. 
 
 PRINTED FOR J. CALLOW, MEDICAL BOOKSELLER, 
 CROWN COURT, PRINCES STREET, SOflO, 
 
 BY G. HAYDEN, BRYDGES STREET, COVENT GARDEN. 
 
 1808. 
 
i//sr, 
 
 
TO 
 
 SIR CHARLES BLICKE, 
 
 SURGEON OF SAINT BARTHOLOMEW'S 
 HOSPITAL. 
 
 Dear Sir, 
 
 Had I been anxious to prefix 
 to these pages a name, which, by its justly 
 deserved professional celebrity might have 
 conferred a sanction on the work, the public 
 ivill agree ivith me, that I could not have 
 selected a more proper one than your own : 
 I wish however, to avail myself of this op' 
 port unity, in order to execute a duty, tvhich 
 is alivays most pleasing to my mind, that of 
 achnotvledging favors received. I beg you 
 
iv DEDICATION. 
 
 therefore to accept this puhlic testimony of 
 the grateful sense that I shall always retain 
 of the numerous marhs of kindness for which 
 I am indebted to your friendship. 
 
 I remain, dear Sir, 
 
 JVith great respect, 
 Your faithful and obliged Servant, 
 
 B. CROWTHER. 
 
IP^TJRODUCTION. 
 
 '\ HEORETICAL reasonings of writers on 
 the nature of scrofula, have not afforded, as 
 far as I know, any improvement in point of 
 surgical practice ; neither has the investiga- 
 tion of the supposed causes of the disease 
 appeared to throw much light on the sub- 
 ject. 
 
 By these means mens' minds have been 
 diverted from what should have been their 
 proper pursuit — that of removing the effects 
 of a disposition known to arise from what 
 is called a scrofulous taint. 
 
 It would probably have been well for 
 
VI INTRODUCTION. 
 
 mankind, if our attention had been thus 
 confined ; and if, when unable to penetrate 
 into the nature of a disease, we had satisfied 
 ourselves with attacking its symptoms in 
 detail. 
 
 In the following pages I disclaim all 
 theoretical disquisition. I shall forbear to 
 enquire whether scrofula ought strictly to 
 be called a hereditary disease or not ; of 
 the following facts, however, I am quite 
 certain, that most of the patients, whom I 
 have seen afflicted with white swelling, 
 were of a strumous habit, and were de- 
 scended from parents of a similar consti- 
 tution. Manv members of such families 
 have been destroyed by pulmonary con- 
 sumption ; and if one parent be healthy, 
 and the other of a scrofulous habit, one 
 child produced by such an union shall es- 
 cape quite free, while the remainder are 
 miserably attacked with the complaint; and 
 
INTRODUCTION. vil 
 
 the children will bear a strong resem- 
 blance in features to that parent, whom 
 thej resemble in constitution. 
 
 In the very valuable posthumous pro- 
 duction of M. PouTEAU, chief surgeon of 
 the Hotel Dieu de Lyon, we find this au- 
 thor deprecate the notion of adopting the 
 phrase of hereditary diseases ; in which 
 respect he has certainly anticipated Mr. 
 John Hunter ; not that I think the sub- 
 ject of such importance, that the friends 
 of either of the deceased authors should at 
 all feel themselves interested in determining 
 this question, especially as it is unconnected 
 with practical utility . — Pouteau says, "Rien 
 n'est done plus erronne generalement que 
 I'axiome tant repete, que le germe des ma- 
 ladies passe des peres aux enfans, aheunt 
 in natos patrum cum semine morhi)' and 
 again we remark in this author his excellent 
 conclusive idea of the impropriety of adopt- 
 
■Siii IXTRODUCTIOX. 
 
 ing the term, hereditary disease. '"' Bornons- 
 nous done simplement ?. avertir que les en- 
 tans ont plus que tous les autres de facheuses 
 dispositions aus maladies dont leurs parens 
 ont etc entichcs ;" This may be considered 
 as a proper view of the subject : but there is 
 no merit attached to this conception of it. 
 For I will venture to atSrm, that when a 
 surgeon said the disease was hereditaiy in 
 the child, he neither adverted to a lameness 
 of the parent in consequence of a disease in 
 the hip, which occurred in his infancy, noc 
 to a strumous aitection of the glands of the 
 neck ; all that could be meant was that the 
 parent vras scrofulous, and that the child 
 partook of a similar constitutional dispo- 
 sition. 
 
 Another ill-founded opinion too generally 
 prevails that this disease arises out of, or is 
 essentially connected with debihty, and this 
 opinion has introduced a mode of treat- 
 
IXTRODUCTIOy. ijt 
 
 ment which in many instances I deem 
 
 highly objectionable. 
 
 Were this notion well founded, how hap- 
 pens it that the practice, deducible from 
 such a theor}% is not found by experience 
 
 prop option ably successful ? that it is not I 
 am fully persuaded, and I appeal to the 
 practitioners of London for the truth of mj 
 assertion. 
 
 From my own obsers^ation, however, I 
 must aver that such an uniformity' in the 
 appearance of scrofula, dependent on a de- 
 bihtated state of constitution, does not exist 
 
 ^^1th us in England ; for many are to be 
 found with strumous affections, who in 
 other respects are healthy and strong. 
 
 To such the cordial and invigorating 
 mode of treatment, I have observed, has 
 not only been of mischievous tendency, but 
 
X . INTRODUCTION. 
 
 has doubtless accelerated the progress of the 
 complaint to its most formidable termina- 
 tion, the suppurative period of the disease. 
 
 In patients of reduced and weak habits, 
 affected with strumous diseases, evacuations 
 of every kind have been avoided, excepting 
 such as regard the health abstractedly con- 
 sidered: support given in these cases has 
 been by nourishing diet, assisted by a class 
 of medicines appropriated to debilitated 
 constitutions. 
 
 In a manuscript of the late Dr. Monro, 
 of Edinburgh, on diseases of bones, when 
 speaking of diseased joints, I find he con- 
 demns the application to the surgeon as 
 useless, and recommends the care of these 
 cases to a good-natured old woman. 
 
 If the surgical practice now adopted were 
 like that handed down to us by some of 
 
INTRODUCTION^. XI 
 
 the earlier writers, 1 confess that the old 
 woman should be preferred; but improved 
 as our present treatment of scrofulous af- 
 fections is, I consider, with great deference 
 to physic, that the majority of strumous 
 complaints come directly within the pro- 
 vince of surgery: and I venture to affirm, 
 that there are no complaints of so calami- 
 tous a nature, which admit of greater relief 
 from the hands of the judicious and expe- 
 rienced surgeon. The idea that scrofula 
 depends upon acrimony of the lymph has 
 passed from one author to another without 
 proof, and without leading to any useful 
 practical purpose. It has served as a cloak 
 for ignorance, and to impose upon feeble 
 minds the semblance of scientific informa- 
 tion. But the mischief has not stopped 
 here; for, in consequence of this hypothe- 
 sis, a class of remedies, which have been 
 supposed to be antidotes to scrofula, but 
 which appear to possess little or no efficacy, 
 have been recommended. 
 
Xil INTRODUCTION. 
 
 This theory has also made an erroneous 
 impression on the pubhc mind, which can- 
 not be too soon removed; viz. that, until 
 the habit be corrected, it is in vain to ex- 
 pect a cure from any surgical application. 
 That this opinion is void of foundation will, 
 I presume, be made sufficiently manifest in 
 the ensuing pages. 
 
 I entreat the medical reader not to mis- 
 conceive me, nor to suppose, that I would 
 insinuate that the advice of physicians in 
 the complaint under our consideration, is 
 unnecessary : I have been assisted by their 
 interference in this, as in other cases of 
 surgery, and shall always consider their 
 assistance useful and respectable ; but there 
 is a distinction between medical practice 
 and medical quackery, which a practical 
 surgeon should ever bear in his mind. 
 
 The communication with which Mr Law- 
 
INTRODUCTION. XUl 
 
 RENCE has favoured me, of bones not suffer- 
 ing enlargement, when scrofulously affected, 
 will not cause the slightest change with 
 respect to the curative indications proper to 
 be observed in the treatment of white- 
 swelling. 
 
 I feel much honoured bj the obliging 
 mention, which Mr. Abernethy has made 
 of me in his lectures, on account of the un- 
 abating perseverance I have exerted for 
 such a length of time in this pursuit. I 
 have been enabled to give so close an at- 
 tention to individual cases, principally from 
 my choice of patients, for I have selected 
 them even from the streets : during my at- 
 tendance on many of these cases, I not only- 
 supported the object of my treatment, but, 
 occasionally the whole of the family. 
 
 Pecuniary aid probably rendered my at- 
 tendance more acceptable, and prevented 
 
Xvi. INTRODUCTION. 
 
 reflections which might have distressed my 
 feeUngs and weakened my exertions. 
 
 To Mr. Ward, surgeon of the Manches- 
 ter Infirmary^ my obhgations are also due : 
 I consider his communications a valuable 
 addition to my publication. 
 
 For the imperfections and inaccuracies of 
 the following sheets, as to composition, I 
 entreat that indulgence, I received from the 
 generosity of the public in the year 1797. 
 
 I consider myself called upon to annex 
 additional observations and cases to those I 
 have already published, from a sense of their 
 real importance ; of the practical information 
 they convey, and more especially from the 
 conviction impressed on my mind, of the 
 advantages, which will accrue, from the 
 adoption of the plan of treatment, which I 
 have recommended in cases of white-swel- 
 ling of the joint. 
 
INTRODUCTION. XVll. 
 
 I embrace also this opportunity of calling 
 upon a late writer of dissertations on white- 
 swelling, to shew, with what pretensions 
 to practical knowledge, he could assert, 
 " There is an universal want of success in 
 the cure of white-swelling," unless it be the 
 meaning of Dr. Herdman to confine this 
 remark to the circle of his own experience. 
 For my own part, as far as an individual 
 can be authorized in making any general 
 deduction from the results of his own prac- 
 tice, I can with truth affirm, that I have 
 witnessed such a great proportion of scro- 
 fulous joints terminating favourably, as fully 
 justifies me in the notice I have taken of 
 Dr. Herdman's assertion. 
 
 If I have omitted hitherto paying the 
 proper respect due to the memory of my 
 late father, with whom I served an ap- 
 prenticeship, my mind nevertheless has 
 been duly sensible of the acknowledged ex- 
 
Xvi INTRODUCTION. 
 
 cellence of his surgical practice, and the 
 worthiness of his character, to which I feel 
 indebted for the kindness which the Gover- 
 nors of Bridewell and Bethlem Hospitals 
 manifested in my favor, by appointing me 
 his successor. It may be some gratification 
 to those friends, who supported me on that 
 occasion, to know, that if my practice has 
 been serviceable to the community, they 
 contributed not a little to the event, by the 
 kind support afforded me on the demise of 
 my father. 
 
PRACTICAL OBSERVAT IONS, 
 
 SECTION I. 
 
 DISEASES OF THE BONES. 
 
 On White- swelling of the Joints, 
 
 At will surely be admitted, that the science 
 of surgery would have made greater progress 
 towards perfection, had writers on the sub- 
 ject satisfied themselves with first pointing 
 out the leading features of a malady, it's 
 symptoms and termination : but, instead of 
 this, they too frequently have endeavoured 
 to establish a theory, which had not prac- 
 tical information for its support, and have 
 disregarded noticing the usual and unerring 
 distinctions of a complaint ; thus sacrificing 
 experience, in favor of a weak, delusive, and 
 speculative doctrine. 
 
( 3 ) 
 
 Theory, justly deduced from a practical 
 acquaintance with disease, will, when acted 
 upon, become and assume the form of prac- 
 tice, which will remain immutable as fact 
 itself. 
 
 Mr. Pott, in his remarks upon amputa- 
 tion, observes, " that a history of this dis- 
 " ease is very much wanted ; and he wished 
 " some man, who had leisure and capacity, 
 " and who had seen business, would under- 
 " take it."* This incomparable writer, and 
 excellent surgeon meant by a history of 
 white-swelling, I am persuaded, a clear, 
 just, and accurate account of the appear- 
 ances, symptoms, and conclusion of the dis- 
 order. 
 
 1 have no theoretical notions to support; 
 and however imperfectly these sheets might 
 have met the wishes of Mr. Pott, so bene- 
 volently expressed by himself, I shall take 
 especial care to avoid the affectation of pos- 
 sessing a species of knowledge, which me- 
 dical science can never supply. 
 
 * Pott's Works, YoK III. Earle's edit. 
 
( 3 ) 
 
 The reader, I hope, will pardon these ob- 
 servations, and credit the assertion, that, 
 however disinclined to indulge in hypothe- 
 tical notions on subjects, which regard any- 
 thing so important as the health of my 
 fellow-creatures, I promise I will never 
 shrink from the consideration of any prac- 
 tical question connected with the subject 
 of my present enquiry. 
 
 Although the mode of cure, which it is 
 my purpose to recommend, depends almost 
 solely on the application of remedies to the 
 integuments, I think it right to premise a 
 general view of the change of structure and 
 appearances which the bones assume, in 
 cases of white-swelling of the joints. 
 
 The bones, in this complaint, are affected 
 in two ways : in the one, they are affected 
 primarily from disease originating in their 
 interior structure; in the other, secondarily, 
 by their articulating surfaces becoming dis- 
 eased, in consequence of a previous affection 
 qf the internal surface of the joint. 
 B 2 
 
'( 4 ) 
 
 In the carious state of a bone, it has 
 been said, that to expedite a cure, exfolia- 
 tion should be promoted; but experience 
 tells us, that exfoliation rarely occurs, and 
 when the complaint does not seem to re- 
 quire it, may we not infer, that it should 
 never be encouraged ?* It is very probable, 
 that if means had not formerly been em- 
 ployed to promote exfoliation, it would 
 have been found an unusual occurrence. 
 The supposed necessity of exfoliation in 
 scrofulous joints, formerly gave rise to aa 
 unnecessary, painful, and mischievous prac- 
 tice, such as the making use of the knife, 
 caustics and cauteries : the last of these re- 
 medies were employed to dry up, what was 
 termed the rottenness of the bones, and to 
 destroy the hypersarcosis or the exuberant 
 fungus with which the surgeons of those 
 days were frequently troubled. f 
 
 * Curatio ad os prsecipue dirigi debet et nisi persanato 
 osse curatio nulla est. — Annotat. Mercklini in Pandolphini, 
 cap. i. Le Clerc on diseases of the bone, cap. iii. 
 , t Observ. Medico Chirurg. Petri de Marchettis de spina 
 ventosa, p. lip. 
 
 Spinae ventositas, quam nuperi dixerunt spinam ventosam. 
 Primus de eo morboj et bene egit (Rhases.) Mali causam in 
 
( 5 ) 
 
 At the same time tents of different kinds 
 were in use to make a passage to, and keep 
 
 Ipso osse esse, et vi.cinam carnem omnemque articulationem 
 iu*-umescere, malum in ambulatione augeri. Si ferro ape- 
 rueris facile sanescere et si os corruptum fuerit non curari, 
 nisi OS extraxeris. — Halleri Bibliotheca Chirurgica, vol. i. 
 Haller's edition of Rhases, 1542. 
 
 Ventositas spinae est ad modum doloris : sed materia in 
 dolore articulorum erit in came et musculis : sed iu vitio 
 spinae haec materia erit in osse, et parte ejus corrumpitur 
 caro vicina ei : et juxta modum acuitatis ipsius materiae erit 
 malitia et velocitas ulcerationis ipsius. De cognitione quo- 
 tiens videris articulum ingrossaricum durabilitate, non deficiet 
 vitium sicut deficit vitium articulorum : sed quoties perdurat 
 in dispositione ipsa fiet acutius ambulando, quare minutio fiat 
 in primo de proximiori loco illinitio, fiat cum eo quod con- 
 fortat locum et solidat articulum : purgetur corpus de fluita- 
 tibus calidis, generetur sanguis humidus modicae acuitatis : 
 supponantur locis semper emplastra ad corroborandum, ad 
 prohibendum manationem superfluitatis ad ea ; et toto studio 
 infrigeditur locus ; quoniam hoc regimine prohibitio fiet 
 quod non corrumpatur os, et remanebit in ipsa dispositione 
 per tempus longum absque ulceratione : quod si aperis illud 
 cum ferro velociter, non de levi fiet glutinatio ipsius, quoniam 
 OS aptura est ad corruptionem : et jam corrupta est pars ipsius 
 et hie non glutinabitur nisi extrabatur os, et totum id quod 
 fuerat corruptnm ex corruptioue ipsius ossis, vel akerius 
 diflicilis erit sanatio ipsius etiam quando aperitur ad extra- 
 hendum os, noli dimittere quod non custodiatur de corrup- 
 tione ossis : alterius cum rebus confortativis, infrigidativis, 
 et prohibitivis. — Rhasis, edit. I486, cap. v. lib.xv. in Museo 
 Britaunico. 
 
( 6 ) 
 
 exposed the carious bone, together with an 
 occasional touch of the actual cautery to fa- 
 cilitate its removal. 
 
 The old writers were sensible of the dif- 
 ference in structure of the epiphyses and 
 the internodial parts of a bone ; and by 
 their notions of the use of the actual cau- 
 tery, it might evidently be inferred, that 
 Until they brought the bone to a state of 
 dryness, they conceived that no exfoliation 
 would take place. 
 
 Since it has been the practice, as far as I 
 have known, or seen, not to dilate the sores 
 to the extent formerly done, no such diseased 
 fungous matter has risen, as the surgeons 
 at that time experienced. It has been 
 thought, and with much apparent justice 
 might be apprehended, that Mr. Serjeant* 
 Wiseman, by the treatment we have just 
 represented, added to that caries it was his 
 intention to remove. Indeed, from the ac- 
 count he himself gives of this practice, we 
 could not form any considerable hopes of 
 
 * Wiseman's Chirurgical Treatisesj fol. edit. p. 298. 
 
( 1 ) 
 
 success ; he tells us in particular of a case of 
 white-swelling of the knee, in which, after 
 he had applied a caustic to make an open- 
 ing to discharge the matter, the actual cau- 
 tery was made use of to expedite exfoliation ; 
 yet he allows that, " while he attended the 
 exfoliation of the bone, the caries increased, 
 and the patient languishing, died at last tabid ." 
 Those pieces of bone, which I have known 
 to come away, have exfoliated, not from 
 the articulating part of the bone, which is 
 called epiphysis, but from the body of the 
 bone : indeed, as Mr. Bromfield* says, des- 
 quamation, in strictness of terms, happens 
 not to all the bones, for instance, the bones 
 of the carpus and tarsus, or the spongy ex- 
 tremities of the cylindrical bones: in these, 
 as he observes, when proper openings are 
 made, the carious part will insensibly crum- 
 ble away and be discharged with the matter. 
 It would appear improper to dwell any 
 longer on a circumstance, which, if allow- 
 ed to take place, is not the consequence of 
 the disorder, but of the officious, and unskil- 
 ful hand of surgery. 
 
 * Bromfield's Surgery, vol. II. 
 
( 8 ) 
 
 If the reader's curiosity should incline 
 him to consider the subject further, he is 
 referred to the commentary of Kortum,* on 
 scrofulous disease : he, therein will find 
 ample reference to an immense number of 
 authors, whom I should have considered it 
 a duty to notice, had their notions been just 
 respecting the complaint, or coincided with 
 those of English surgeons. This work I 
 have perused; but I rather consider it as 
 forming a collection of the opinions of 
 others, than containing any thing new of 
 the author upon the subject. As a book of 
 reference, Kortum is certainly intitled to 
 praise, on account of his indefatigable re- 
 search into the writings of other authors ; 
 and to gentlemen called upon to write an 
 inaugural thesis on scrofula, it will be use- 
 ful, as affording abundant matter for re- 
 flection, 
 
 Mr. John Hunter remarked, that a dis- 
 eased bone and a dead bone were very 
 different, and had surgeons, instead of 
 theorising, adverted to the fact, that the 
 
 * Kortum de Vitio ScrofulosOj torn. II. p. 292. 
 
( 9 ) 
 
 ends of the bones do not exfoliate in this 
 complaint, much pain and mischief would 
 have been saved their patients at this period : 
 some practitioners do even still speak, and 
 act, as if such an occurrence could take 
 place. 
 
 The spina ventosa, or scrofulous caries of 
 the bones of a joint, is a malady to which 
 young people are most liable.* 
 
 Writers have supposed, that the peculiar 
 texture of the epiphyses, or the ends of a 
 bone, caused them to be more subject to be 
 strumously affected, than their middle or 
 harder part.f 
 
 We must admit the fact, though we are 
 at a loss to account for it, that the harder 
 parts of a bone are more susceptible of the 
 venereal virus, than the softer parts, and 
 that the extremities, or heads of a bone are 
 much more frequently liable to scrofula; 
 still, instances do occur, which prove that 
 
 * Joannis de Gorter Chirurgia Repurgata, p. 49 et 50. 
 f Le Clerc on Diseases of the Bones, cap. iii. 
 
( 10 ) 
 
 every part ot a bone is subject to venereal 
 as well as to strumous affection. 
 
 I noticed in my former edition, published 
 in the year 1797, that the bones became 
 enlarged when affected by scrofulous ca- 
 ries ; and whatever may be my reasons for 
 changing my opinion with respect to this 
 circumstance^ I have to offer in vindication 
 of having published it, that every author to 
 my knowledge, had spoken of the com- 
 plaint in the way I did ; but this statement 
 should never have formed an excuse to my 
 mind for committing a practical error, did 
 not the actual examination of the disease lead 
 me, as it has done others, to the conclusion, 
 that the bones in some cases of white-swel- 
 ling did really suffer expansion. I shall re- 
 peat what I then offered on this subject, 
 " that unless a patient apply to a surgeon 
 in an early stage of this disorder, it is in 
 some cases very difficult to speak w ith cer- 
 tainty as to the exact state of the joint; for 
 under certain circumstances, white-swel- 
 lings very much resemble each other in ex- 
 ternal appearance.'* 
 
( 11 ) 
 
 I have shewn to my medical friends, some 
 diseased joints, in which, upon examination, 
 it was impossible to decide with accuracy, 
 as to the state of the parts : some of the 
 cases, they, as well as myself, considered 
 only as an enlargement of the bone ; but, 
 after the application of leeches, and an ar- 
 tificial drain being kept up from the integu- 
 ments, covering the joint, there did not ap- 
 pear the smallest enlargement of the heads 
 of the bones. In other instances, in which 
 it was imagined that the complaint was mere- 
 ly an affection of the soft parts, it turned out 
 on recovery, that the bones also had suf- 
 fered enlargement. I freely confess, that 
 the idea of enlargement of the extremities 
 of the bones, rested upon the most attentive 
 examination I could give to the patient's 
 case, as well as the authority of most sur- 
 geons who have written upon the subject ; 
 but I have been unable to produce a single 
 specimen of the bones being really spread. 
 It is always a pleasure with me to correct an 
 error, which I may have unwarily promul- 
 gated ; and I scorn to shelter myself under 
 the impression, that, because other practi- 
 
( 13 ) 
 
 tioners of the greatest celebrity, have really 
 committed the same mistake, I am there- 
 fore more excused. The profession of sur- 
 gery is differently circumstanf:ed from other 
 professions, as the errors committed in our's, 
 if persisted in, may affect the dearest inte- 
 rests of mankind ; and the sooner detected 
 or acknowledged, the earlier will the science 
 of surgery reach perfection, and our fellow- 
 creatures be benefited. In this recantation, 
 I beg it to be observed, that, in the state- 
 ment which I have given to the public, re- 
 specting my examination of diseased joints, 
 while attached to the person of the patient, 
 I have not a single sentiment to retract. 
 The supposition of enlargement, and the 
 caries of the bones, which were formerly 
 thought to be necessarily connected with 
 this expansion, have often, I am apprehen- 
 sive, inclined surgeons to resort to amputa- 
 tion. But if surgeons would make it a rule 
 not to think of removing a limb, but with 
 the view to save the life of the patient, the 
 correction of this opinion would not be of 
 that practical importance. To those how- 
 ever, who practise more from what they 
 
( 13 ) 
 
 read, than any actual knowledge or expe- 
 rience of the subject, it is very necessary to 
 state, that, however appearances may justify 
 in some cases of white-swelling, the notion 
 of enlargement of the ends of the bones, yet 
 that they really have not been found en- 
 larged, but in several instances are in fact 
 reduced in their size by the effect of caries. 
 
 Mr. Pott,* in his remarks upon amputa- 
 tion, speaks of bones in white-swelling be- 
 coming enlarged, and he first maintained 
 this opinion, with regard to the bodies of 
 the verterbr<E affected by scrofulous caries : 
 but this writer, as every fair and candid 
 practitioner ought, embraced the earliest 
 opportunity of correcting this mistake, in 
 his second publication on curvature of the 
 spine, wherein he says, ** In the first edition, 
 " I had described the bones, on which the 
 *' disease had seized, as being enlarged 
 *' and spread ; upon repeated enquiry and 
 " examination, I am convinced that they 
 " are not." It is now more than four years 
 since Mr. Lawrence, Anatomical Demon- 
 
 * Vol. III. 
 
( 14 ) 
 
 strator at Saint Bartholomew's Hospital, en- 
 quired of me, whether I had seen instances 
 of the bones in white-swelling being en- 
 larged, for, if I had, it was a circumstance 
 new to him, as not a single specimen was 
 to be found in the museum of the Hospital, 
 or had ever occurred to him, notwithstand- 
 ing the constant and repeated opportunities 
 which have been afforded him, in collecting 
 and dissecting diseases. My own practice 
 has given me some opportunities, after the 
 removal of the limb, to investigate the ac- 
 tual condition of the joint, and the cases, as 
 far as external examination could determine, 
 would have led any one to imagine the bones 
 were spread; they certainly seemed to be 
 so, yet, upon accurately investigating them, 
 after dissection, they were not in fact the 
 least increased in bulk. I believe this gen- 
 tleman to be the first person who has made 
 this important remark, which I conceive it 
 the more necessary to notice, as I fear that 
 the idea of the tumified state of the bones, 
 in cases of diseased joints, might, if not con- 
 tradicted, induce some practitioners to have 
 recourse to amputation: the public there- 
 
( 15 > 
 
 fore, and myself particularly, are obliged to 
 Mr. Lawrence, for this important and va- 
 luable practical observation. I would wil- 
 lingly do justice to every writer, as well as 
 practitioner; and hope to manifest such a 
 disposition, by remarking, that Mr. Cooper, 
 in a work lately published.* thus expresses 
 himself: " 1 have been in the habit of 
 frequently inspecting the state of the 
 numerous diseased joints, which are an- 
 nually amputated in Saint Bartholomew's 
 Hospital, and though I have long been 
 attentive to this point, my searches after 
 a really enlarged scrofulous bone have 
 always been in vain.'' This is strong 
 confirmation of Mr. Lawrence's opinion; 
 but it is singular, that Mr. Cooper should 
 allow to the spina ventosa that expansion 
 which he has denied to white-swelling. f 
 Did this gentleman not know, that the spi- 
 na ventosa of the joints, has been considered 
 as scrofulous caries of the ends of the bones ? 
 My memory serves me sufficiently well, to 
 
 * First Lines of the Practice of Surgery, and a concise Book 
 of Reference to Practitioncrg. By Samuel Cooper, 
 t Page 117. 
 
( 16 ) 
 
 have noticed in an edition of Motherby's 
 Medical Dictionary, that the scrofulous ca- 
 ries of the spine might with propriety be 
 called the spina ventosa of the vertebrae. 
 Wiseman, the best of the early English 
 writers upon surgery, considered scrofulous 
 affection of the bones and spina ventosa as 
 one and the same complaint. Every sur- 
 geon acquainted with white swelling must 
 have regarded the distinction with respect 
 to the diseases which affect the bones 
 connected with the articulation in the 
 manner which I have before spoken of 
 them. 
 
 It is proper to observe, that when Mr. 
 Lawrence favored me with this practical 
 truth, that he, as well as myself, in consi- 
 dering the subject, was aware that the spina 
 ventosa of joints and scrofulous caries of 
 these parts were diseases of the same na- 
 ture. Hevin, a very late writer, has made 
 the following remark : 
 
 " Le spina ventosa attaque plus ordinaire- 
 " ment les enfans que les adultes, parceque 
 
( 17 ) 
 
 ^' leurs OS approchent davantage de la na- 
 *' ture des parties molles ; il peut occuper 
 *' toutes les parties des os ; mais il arrive plus 
 " particulierement aux, epiphyses et aux os 
 *^ spongieux."* 
 
 Mr. Benjamin Bell, speaking of the 
 spina ventosa, observes, f " but v^hen the 
 " disease fixes on any of the large joints, 
 *^ although it seldom fails to terminate in 
 ** sores at last, yet it commonly proceeds 
 " to an ulcerated state in a more gradual 
 " manner, nor does any remedy, with which 
 " we are acquainted, prevent its progress. 
 *' In this situation it lays the foundation of 
 " what is usually termed a white swelling." 
 
 This author does not speak of the spina 
 ventosa as accompanied with a swelling of 
 the bone, although he observes in another 
 part of the same volume,^ *' when joints 
 
 * CoKrs de Pathologic et de Therapeutique Cbirurgicaies, 
 troisieme edition augmentee de Remarques et Observations 
 importantes. Par Prudent Hevin, 1793. Vo]. il. p. 376, 
 
 f Beil, vol. I. p. 307. 
 
 % Ibid. vol. I. p. 258. 
 
 C 
 
( 18 ) 
 
 *' affected in this manner are dissected, 
 
 *' either after death or after amputation of 
 
 " the member in the first stages of the 
 
 '* disease, the soft parts seem not to be 
 
 '' much injured; but in all, even the shghtest 
 
 '* that I have seen, the whole ends of the 
 
 *' bones, or their epiphyses, are enlarged." 
 
 KoRTUM,* on scrofulous affections, speaks 
 of the bones being expanded; but, it is very 
 extraordinary that he should describe the 
 complaint as prpceeding from a scrofulous 
 or rickety source, as I have never seen a 
 case of scrofulous caries arise from a rickety 
 disposition. A mistaken opinion was seve- 
 ral years ago given on this subject by a 
 surgeon of eminence; when a little boy was 
 brought to him, with a disease of the knee, 
 he told the friends it was only the rickets, 
 which cold bathing, country air, and time, 
 
 * Equidem definio spinam rentosam et psedarthrocacen 
 per ossium, praecipue spongiosorum et minorum ssepe tamen 
 etiam majorum, ad articulos potissimum et epiphyses infla- 
 maiionem cum carie junctam, saepe non tamen semper dolorifi- 
 cam, ulcerapartium mollitim foeda sibi adsociantem, difficilime 
 sanabilem, et a causa scrofulosa vel rachitlca profectam.'sr? 
 Tpni, ii. p. 298, 
 
( 19 ) 
 
 would remove. In this boy's complaint the 
 knee was enlarged; there was no fluctuation 
 in the joint, and little uneasiness on moving 
 it; and it was one of those cases in which 
 the condyles of the femur appeared to be 
 increased in their dimensions. I gave my 
 opinion accordingly, and the relations were 
 satisfied that my notions respecting the child 
 were correct, and that it was in fact a white- 
 swelling and not the rickets. In conse- 
 quence of this opinion I have since been 
 induced to examine particularly many chil- 
 dren who have been brought to me, on ac- 
 count of scrofulous affection, and I have 
 always remarked that they were totally free 
 from any trace of rickets. 
 
 In rickety children we do not find one 
 joint only affected, for the corresponding 
 limb shews marks of the same disease. — 
 Mr. Cheston* says, " It has indeed been 
 " commonly advanced, tliat the bones are 
 " almost always enlarged; this I never ob- 
 " served, unless in young subjects where it 
 
 * Vide Cheston's Pathological Observations and Enqui- 
 riesj p. 118. 
 
 C 2 
 
( 20 ) 
 
 '' might have been comphcated with the 
 ^' rickets, though I have examined a great 
 *' number of them w^hen injured by this 
 ^' complaint. I am incUned to think that 
 ^' this notion either arose from the deceit- 
 '' ful feel through the diseased integuments, 
 '^ &c. or its being confounded v^ith spina 
 *' ventosa." I have seen but a very few 
 joints dissected after amputation, but in 
 those affected with spina ventosa or scrofu- 
 lous caries which I have had an opportunity 
 of inspecting, the bones had not undergone 
 any increase in size, although they were 
 softened in their texture, and excavated 
 from within outwards. In those cases where 
 the bones are injured in consequence of 
 disease occurring first within the cavity of a 
 joint, although they are frequently deprived 
 of their cartilaginous covering, ^nd some^ 
 times even suffer loss of substance, yet the 
 structure of the bone is not changed ag 
 happens in the scrofulous caries. 
 
 I have, on the authority of Wiseman, 
 regarded the spina ventosa of a joint as a 
 species of white-swelling, and I am cqx\' 
 
( 21 ) 
 
 viticed of the propriety of this arrangement; 
 for surgeons, however accurately they pro- 
 fess to discriminate between the different 
 kinds of this disorder, yet, in practice have 
 found themselves frequently mistaken as to 
 the parts of the joints which were diseased. 
 The distinctions are not of much import- 
 ance, for, as far as my experience and ob- 
 servations of the disease have extended, the 
 proper treatment is essentially the same in 
 all cases of white-swelling. Rhazes, Avi- 
 CENNA, Pandolphin, and most other authors 
 have informed us that the spina ventosa is a 
 disease of the bone ; and Mercklin, a judi- 
 cious commentator on Pandolphin's Trea- 
 tise on this subject, says, that in this disease 
 the bones are first and principally affected 
 in their interior part, and that the disease 
 of the bone always precedes that of the 
 flesh: hence, if the disease of the bone and 
 that of the flesh are discovered at the same 
 time the former must have existed before 
 the latter.* 
 
 * Malum nostrum in offis potius corruptione qnam in ex- 
 ulceratione carnis consistere, hae fere evincunt rationes, qnin 
 ossa et quidem interius primo ac primario corrumpuntur 5 
 
( 22 ) 
 
 Mr. Samuel Cooper, in discoursing on 
 spina ventosa, says, " when matter forms 
 
 " in the internal structure of a bone the 
 
 " disease has received this whimsical name. 
 
 " The complaint," he farther says, " is most 
 
 " frequently met with in unhealthy chil- 
 
 " dren, and it begins with a dull, heavy, 
 
 '' deeply seated pain, the limb appearing 
 
 " outwardly quite sound. In general the 
 
 '^ disease is not ascertained before the af- 
 
 " fected bone becomes expanded ; at length 
 
 " the matter arrives beneath the perios- 
 
 " teum, and a tumour, resembling a deep 
 
 " seated abscess, is produced. 
 
 " As soon as the nature of the case is 
 *' ascertained the matter ought to be eva- 
 '' cuated through a perforation made into 
 " the bone by a small trephine : unfortu^ 
 *' nately it is difficult to know the early 
 *' existence of the disorder with certainty. 
 " Exfoliation generally takes place after 
 " the termination of the case. Amputa- 
 
 ossisque corruptio semper prascedit corruptionem carnis ; 
 atque hinc si ossis et carnis vitium simui apparet, illud semper 
 hoc prius extit't. — Annotat Mercklini Pandolphini, cap. i, 
 p. 196 et 197. 
 
( 23 ) 
 
 " tion ought not to be practised unless the 
 
 " immediate preservation of life should be 
 
 *' at stake. Bark, wine, good air, and 
 
 " nourishing diet are peculiarly necessary 
 
 " in this tedious and debilitating sort of 
 
 case. 
 
 This gentleman's notions do not coincide 
 with those I have formed on the subject ; 
 the disease has been supposed to have ob- 
 tained the name from the pungent pains ex- 
 perienced in the part, and the inflated state 
 of the superincumbent soft parts investing 
 the bones ; and I beg to observe, it is a title 
 by far less exceptionable and ridiculous than 
 many this author has been obliged to notice 
 in his system of surgery. 
 
 The spina ventosa, when seated in the 
 body of a bone, may require, and will ad- 
 mit of the application of the trephine, but 
 this would be injurious in the same com- 
 plaint if it attacked the extremities of the 
 cylindrical bones; here there is no matter to 
 discharge, and consequently no good end to 
 answer by it; but, on the contrary, from. 
 
( 24 )- 
 
 the use of the trephine, much mischief 
 might be communicated to the cavity of 
 the joint by the inflammation which would 
 most probably be excited. 
 
 I shall arrange the several circumstances, 
 connected with white-swelling., under the 
 following heads : — first, I shall consider it as 
 a disease originating in the substance of the 
 bones connected with a joint ; and secondly 
 as an affection of the internal cavity of a 
 joint, independent of any primary disease of 
 the bones, and this latter head will be sub- 
 divided according to the character of the 
 inflammation by which the disease is accom- 
 panied, which may be either acute or chronic. 
 
 Cases of white-swelling, originating in a 
 scrofulous affection of the bones, have re- 
 covered, and I believe such instances would 
 have been more frequent, had a remedy 
 been known, capable of arresting the pro- 
 gress of the disease in the bone. For, unless 
 this can be accomplished, the malady of 
 the bone will go on, till it pervades the 
 joint, and produce the same eiFects on the 
 
( 25 ) 
 
 ligaments and articulating surfaces of tlie, 
 ends of the bones, which occur in the white- 
 swelHng, where the disease first begins in 
 the cavity of the joint. 
 
 Patients, in the most early stage of 
 this species of white-swelling, suffer pain, 
 which they describe to be in the bone it- 
 self. The joint in this case can be extended, 
 or is capable of being bent with the most 
 perfect ease and facility ; the part will bear 
 handling, without the patient manifesting 
 any pain, and the integuments will admit 
 of being pinched up and will be found un- 
 affected. 
 
 As the disease advances, the soft parts 
 participate in the malady; fluids are ef- 
 fused within the articulation and different 
 parts about the joint; the distension in- 
 creasing, the joint becomes painful to the 
 touch, or on motion, inflammation at length 
 supervenes, and ulceration follows. Should 
 the parts now be exposed by dissection, the 
 ligaments will be found in a thickened state, 
 and sometimes destroyed; and in diseases 
 
( 26 ) 
 
 of the knee, the interarticular cartilages, I 
 have also noticed to have been absorbed. 
 The ends of the bones will be found carious, 
 and their articulating surfaces more or less 
 deprived of the cartilaginous covering. In 
 those instances, in which the bones suffer 
 only simple abrasion, they will not be found 
 otherwise altered in their structure. 
 
 Much has been said respecting the state 
 of the integuments, and more than, from 
 any peculiarity of affection, they are general- 
 ly entitled to. In injuries of the dura mater, 
 the scalp becomes affected, and a pufiy 
 tumour is formed, which has been well de- 
 scribed by Mr. Pott, as ascertaining the 
 precise extent of inj ury the dura mater has 
 sustained, and the place for the application 
 of trephine. So do also the external parts 
 sympathize with the disease going on with- 
 in a joint ; they manifest a puffy appearance, 
 fluid is collected beneath them, inflamma- 
 tion takes place, and suppuration follows : 
 the irritation and drain, which they pro- 
 duce, frequently destroy the patient, or 
 oblige him to submit to amputation. 
 
( 27 ) 
 
 In the spina ventosa, or the true scrofu- 
 lous joint, the sufferings of the patient are 
 so shght, that the swelhng of the joint is 
 often the first circumstance which Qxcites 
 attention. The skin is pecuharly palhd, 
 and when the integuments are pinched up 
 they will be found thickened, though not 
 oe-dematious. It is remarkable, that, in this 
 indolent sort of white-swelling, the bones 
 sometimes become carious, and the liga- 
 ments diseased, and all this is accomplish- 
 ed with little uneasiness ; besides the health 
 is not so materially hurt as might be sup- 
 posed. But, as the complaint makes further 
 progress, the joint becomes more consider- 
 ably distended ; a fluctuation of fluid is more 
 evidently to be perceived, and the disten- 
 tion of the joint increasing, inflammation 
 and suppuration occur. It is at this time^ 
 w^hen the patient's health is in the greatest 
 hazard, and suffers more rapidly than at 
 any other period of the complaint. The 
 pain, which is first observed, is always with- 
 in the joint, and the integuments and ten- 
 dinous parts suffer in consequence of the 
 articulation being affected. 
 
( 28 ) 
 
 The elasticity, which writers mentiofi^ as 
 perceptible to the touch, on examination, is 
 very similar to the sensation that deep-seat- 
 ed abscesses give ; or what might be ex- 
 pected from feeling a fluid through parts, 
 which are in a diseased and thickened state. 
 
 These parts are sometimes much disten- 
 ded by the fluid which is eflused, and the 
 whole joint feels so hard and tense, that the 
 case might easily be mistaken for a mere 
 enlargement of bone, as the smallest fluc- 
 tuation is not to be felt. I have repeatedly 
 seen an artificial purulent discharge, con- 
 tinued for a very short time, so eflectually 
 relieve the parts from their distended state, 
 as entirely to remove the delusion. 
 
 If the complaint be suflered to take its 
 usual progress, the ligaments and cartilages 
 will be destroyed, the articulating surfaces 
 of the bones eroded, and the patient will 
 die hectic, from the irritation and great dis- 
 charge, arising from the repeated suppura- 
 tions, which always attend the latter stage 
 «f white-swelling. 
 
( 29 ) 
 
 In the spina ventosa, ot the scrofulous 
 caries of the ends of the bones, the integu- 
 ments are sometimes differently affected, 
 from the manner above- described, for, in- 
 stead of ordinary inflammation and sup* 
 puration, fungous excrescences arise and 
 elevate them, and the skin seems to be 
 destroyed rather by absorption than any 
 positive disease; for, in these instances 
 the integuments neither slough nor ul- 
 cerate. 
 
 These fungi, by a probe, w^ill be found to 
 lead to diseased bone, and in some instances 
 into the cavity of the joint. The interspace 
 between these excrescences, from the in- 
 flated appearance of the integuments, might 
 incline the practitioner to believe, that he 
 felt fluid fluctuating underneath. This 
 sensation is delusive ; but, I would recom- 
 mend, particularly in this state of the com- 
 plaint, to avoid the use of the knife, as 
 diseased parts will ill bear the attack of 
 inflammation; and, I have observed, that 
 they suffer less by openings, which the dis- 
 ease spontaneously makes, 
 
( 30 ) 
 
 Although I generally condemn the ma- 
 king openings to let out fluid, or matter 
 situated externally to the joint, because it 
 will be found most generally capable of 
 being absorbed ; yet, in some instances, in 
 which matter is collected under the integu- 
 ments, and in some cases under the fascia 
 of the thigh, I have let it out by means of 
 a trocar, for the purpose of preventing its 
 diffusing itself, and destroying the cellular 
 membrane. The puncture will be filled 
 with coagulabie lymph, which may, with- 
 out exciting fresh irritation, be easily broke 
 through, and the contents evacuated at the 
 pleasure of the practitioner through the 
 same aperture. 
 
 " The swellings," sa}'S Wiseman, " af- 
 " fecting the joints in this disease, are of 
 " two sorts ; both of them are made by 
 " congestion, and increase gradually, yet 
 " differ in that, the one ariseth externally 
 *' upon the tendons, and between them 
 " and the skin, or between them ancj the 
 *' bone; the other internally, within the 
 " bone itself. 
 
( 31 ) 
 
 ^' That which ariseth externally, afFecteth 
 *' the ligaments and tendons first, and some- 
 *' times relaxeth them to such a degree, that 
 *' the heads of the joints frequently separate 
 *' from one another, and the member ema- 
 ^- ciates and grows useless; but for the most 
 '^ part, the humour overmoistening the liga- 
 " ments and tendons, produceth a weakness 
 " and uneasiness in the joint, raising a tu- 
 *^ mour externally, and in progress, the 
 *' membranes and bones are corroded bv 
 *' reason of the acidity of the humour, yet 
 *' it is much hastened, if, upon a supposi- 
 *' tion of dislocation they consult the bone 
 ^' fetters." 
 
 That fluids, as well as abscesses, arise be- 
 tween the skin and tendons, I know very 
 well, having seen such cases, which were 
 taken for .white-swelling; but, from the 
 account which this surgeon has given, and 
 I have quoted, it is evident to me, that 
 he has taken an effect for a cause, and that 
 the complaint was originally an affection 
 within the joint, and not exterior to it; and 
 that the external parts became in a swollen 
 
( 32 ) 
 
 diseased state, as the ordinary effect of the 
 internal disease. 
 
 This writer appeared to be aware how fal- 
 lacious to the touch these cases were, by 
 giving the following caution. 
 
 ** But, if through want of such a treat- 
 ment they grow excessively swelled, and 
 the humour incapable of being pressed 
 back or discussed, you may shrewdly ex- 
 pect the bones corroded ; for, that swelling 
 is for the most part raised by an hypersar- 
 cosis within, and ought not to be opened 
 without a prediction of a caries ; for, 
 however it may, by a seeming fluctuation, 
 be thought to have matter, yet, upon 
 opening, it will only discharge a gleet, 
 and the hypersarcosis will thrust out into 
 a fungus. If, in some particular part, 
 there do visibly appear suppuration, and 
 upon aperture, there do discharge an al- 
 bugineous matter, you may conclude the 
 bone under it is rotten, especially if it be 
 hand or foot, and the longer you delay 
 
( 33 ) , 
 
 *' the opening, the more rotten the bones 
 •' will be."* 
 
 There is an evident puffiness of the joint 
 in white-swelling, which might induce a 
 young surgeon to imagine, that fluid was 
 , situated beneath the integuments ; this feel 
 is fallacious. We ought never to think of 
 making openings but for the purpose of let- 
 ting out matter, which now and then is 
 collected under the fascia, and cannot be 
 absorbed : if this be the case, a puncture is 
 sufficient for the purpose, applying after- 
 wards simple dressing and strict bandage 
 from above downwards. The presence of 
 symptoms attending the formation of matter, 
 or their absence, will sufficiently guide us 
 in discriminating between the production of 
 pus, and that merely inflated state of the 
 soft parts, which is the ordinary consequence 
 of affection of the joint, or of a distempered 
 bone. 
 
 In cases of diseased bones, the parts, 
 
 * Wiseman's Chirurgical Treatise, folio edit. p. 26i and 
 262. 
 
 D 
 
( 34 ) 
 
 which cover them appear affected, and they 
 afford to the examiner the feel of fluid very 
 perceptibly to the touch. I shall give such 
 part of a case as is interesting, and applies 
 to this part of our subject. 
 
 A man applied to me, on account of a 
 tumour, occupying the whole extent of the 
 frontal bone ; it was thought it contained a 
 considerable quantity of fluid, and if an 
 aperture were made, the swelling would 
 subside; but, upon the part being punc- 
 tured, no evacuation took place, and the 
 tumour preserved its elasticity. By the in- 
 troduction of the probe I discovered that 
 the bone was rough in some parts and 
 denuded in its whole extent. I brought 
 the lips of the orifice together, which healed 
 by the first dressing, and sent him to the 
 hospital. The surgeons were positive that 
 the swelling did contain fluid, an opening 
 was made into it, but not any thing fluid 
 escaped. This case is mentioned, as a cau- 
 tion to practitioners, to be guarded in their 
 prognostic, when they make openings into 
 such tumours. 
 
( 35 ) 
 
 As we are on the subject of diseased bones, 
 it may not be improper to mention, that I 
 have, in cases of abscess, formed in the course 
 of the tibia, let out the matter, at a distance 
 from the bone, by pressing the tumour on 
 one side, and then puncturing it : on the in-^ 
 troduction of the probe, in such instances, 
 the bone has been found rough and denuded. 
 Simple dressings were applied, and over 
 them a compress of linen pressed out of the 
 saturnine lotion, and the cure was effected 
 without exfoliation. 
 
 In a case of a venereal node, which a 
 gentleman had on the shin-bone, this treat- 
 ment happily succeeded, with a proper 
 mercurial course ; and this patient also re- 
 covered without exfoliation. 
 
 If absorption of the fluid or matter does 
 not take place, the tumour had better be 
 punctured, to preserve the skin and prevent 
 the occurrence of sloughing. 
 
 In a compound oblique fracture of the 
 tibia, the lower portion was drawn under 
 
 D 2 
 
( 36 ) 
 the upper, the pointed extremity of which 
 projected ; a fungus arose, which covered 
 the bone and the space of an inch surround- 
 ing it : I introduced a layer of lint between 
 it and the integuments, and then covered 
 the surface with the same : the extremity 
 of the bone was absorbed, and the patient 
 was cured without exfoliation ; the fungus 
 shrunk up, and the sore healed by bandage 
 and simple dressing. I regretted at first not 
 having removed the end of the bone at the 
 time of the accident; but, from the pleasing 
 termination of this case, I am happy in 
 having acted otherwise. 
 
 I lately amputated above the knee, under 
 circumstances litde desirable ; the patient's 
 health was hardly such as to justify the 
 operation ; it was performed at his own re- 
 quest ; and the best amends for the anxiety 
 I suffered on his account are that he re-, 
 covered. 
 
 On my first dressing, although muscles 
 and integuments were amply saved, I ob- 
 served the parts to be flabby yet still in 
 
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( 37 ) 
 
 contact, they yielded abundant serous dis- 
 charge, the soft parts investing the bone, 
 I anticipated would not keep their situation, 
 I therefore confined them by more slips 
 of adhesive plaister, and directed bark and 
 wine with a more nourishing diet. 
 
 The patient was afterwards seized with 
 hysteria, which prevented him from taking 
 sufficient food : the integuments and mus- 
 cles retracted, and the bone protruded about 
 an inch and a half. The success of the for- 
 mer case taught me not to be too busy with 
 the exuberant granulation, which afterwards 
 covered the bone ; but the circumstance 
 of having saved integuments sufficiently, 
 and know^ing I could recover them by proper 
 attention, and the use of adhesive plaister, 
 afforded me a little comfort. The end of 
 the bone was absorbed, at least it never ex- 
 foliated, and the patient recovered with a 
 well-formed stump. I am persuaded, that, 
 if the fungus had been destroyed in either 
 case, exfoliation must have unavoidably 
 -taken place. 
 
( 38 ) 
 
 I was many years ago present at an am- 
 putation above the knee, in a case of white- 
 swelling ; in which, the knife, in making 
 the second circular incision through the 
 muscles, had nearly divided the bone, so 
 exceedingly soft was its texture. This cir- 
 stance induced the surgeon to detach the 
 muscles further up, and saw the bone higher: 
 the same occurrence happened ; the knife 
 was again let into the bone, and the remo- 
 val of the limb was finished by the saw. 
 No exfoUation took place, and the operator 
 obtained the credit of having made a most 
 excellent stump. 
 
( 39 ) 
 
 SECTION U. 
 
 Anchylosis. 
 
 Patients, when the articulating sur- 
 faces of the bones are affected, have often 
 been encouraged by practitioners to hope 
 that the complaint may terminate in anchy- 
 losis, but this unfortunately is a very in- 
 frequent occurrence, and cannot reasonably 
 be expected whilst the disease is suffered to 
 proceed. Anchylosis is a process of health, 
 and as such cannot be expected to occur 
 until the progress of the complaint in the 
 bone has been arrested. I shall not attempt 
 to determine whether the reason I have al- 
 ready assigned will account for the infre- 
 quency of anchylosis in this disorder; yet, as 
 a proof how seldom it does occur, I assert, 
 that I have neither seen before, nor since 
 my first publication, more than four cases 
 of the knee, and one of the elbow, anchy- 
 losed by ossific union. 
 
( 40 ) 
 
 It is rather extraordinary that foreign sur- 
 geons should have regarded this salutary 
 effort of nature in the light of morbific af- 
 fection ; it is therefore, as they have so 
 considered the subject, not to be wondered 
 at, that a variety of liniments, the use of 
 warm-baths, fomentations, and exercise of 
 the limb, should have been recommended. 
 
 Indeed it is curious that we should find, 
 especially in the French authors, anchylosis 
 treated distinctly from the cause which pro- 
 duced it: for, as far as a considerable share 
 of experience entitles me to give a practical 
 opinion, with, respect to anchylosis of joints, 
 I can affirm, with the strictest truth, that it 
 should always be considered as tl^ie effect of 
 disease. 
 
 Many objections to keeping the joint in 
 a state of rest have often been urged by the 
 patients or their friends, from an apprehen- 
 sion that the joint would become rigid, but 
 I have hitherto never found rest produce 
 such an effect. In every case under my 
 care, of white-swelling of the knee, the 
 
( 41 ) 
 
 limb has been kept extended, in some in- 
 stances for many months ; and, in a few 
 cases, two, three, or four years, yet the 
 joints have never been rendered rigid or 
 their motion impaired. It appears to me, 
 that joints becoming rigid is rather a conse- 
 quence of disease than arising from a posi- 
 tion of the hmb ; and I am confirmed in 
 this, by having seen several joints rendered 
 rigid by the disease, completely set at liber- 
 ty, merely by the effects of a purulent drain 
 derived from the integuments surrounding 
 the diseased joint. 
 
 On the subject of rest I have read M. 
 David's Prize Dissertation, translated by 
 JusTAMoND ; it proves the efficacy of abso- 
 lute quietude, but it also shews the miserable 
 want of appropriate surgery. Whoever will 
 give the work a perusal will probably think 
 with me, that some lives were sacrificed ; 
 and I am sure considerable suffering on the 
 part of the patient, in many cases might 
 have been prevented by suitable remedies. 
 Other instances of knees anchylosed by a 
 conjunction of soft parts, have also occurred 
 
( 42 ) 
 
 to my notice; which joints, though inca- 
 pable of flexion, yet admitted a degree of 
 motion, just enough to prove, that ossific 
 matter had not produced the union. Fortu- 
 nately for these patients, the leg and thigh 
 had been kept, during the cure in an ex- 
 tended state. Perfect quietude of the limb 
 is requisite for the recovery of a diseased 
 joint, but more particularly, if the part 
 should be in a disposition to anchylose. If 
 the disease is in the knee, too great atten- 
 tion cannot then be paid to keep the leg 
 extended ; if it be in the elbow joint, that 
 the arm be kept bent ; for inattention to a 
 proper position of the limb has often ren- 
 dered it useless, though the complaint has 
 been cured. 
 
 So indispensably necessary is rest, in the 
 cure of diseased joints, that when called 
 upon to see, with others, a white-swelling, 
 I have entreated them to forbear giving the 
 limb any exercise, intimating at the same 
 time, that the best means to avoid a stiff 
 joint, is to cure the complaint, and to pre- 
 
( 43 ) 
 
 vent the occurrence of inflammation and 
 its consequence. 
 
 A medical student has this summer seen 
 a patient of mine at Sunderland, whom, 
 above a year ago, I recommended to the 
 sea, having previously established a large 
 and permanent issue on each side of the 
 knee. This gentleman's joint, I considered, 
 from the inflammatory violence of the dis- 
 ease, would have continued rigid so long as 
 he lived; but I was agreeably surprised, 
 when it was communicated to me, that he 
 had recovered the use of the joint, nearly as 
 perfectly as the other, and that it is also re- 
 duced to its natural size. 
 
 I have experienced similar instances of 
 such good fortune, but the one just recited, 
 from all the circumstances attending the case, 
 really astonished me. This instance, and 
 others I have seen in the course of my prac- 
 tice, go a considerable way to establish the 
 opinion I have before advanced as probable, 
 that anchylosis is rather the effect of disease, 
 than arising from the circumstance of po- 
 
( 44 ) 
 
 sition, or of the limb remaining at rest for a 
 great length of time. 
 
 Had the knee been kept bent, a circum- 
 stance arises from such a position of the 
 limb, which does not occur in the extended 
 attitude, and which is, that the muscles 
 become shortened ; and bj this means the 
 difficulty of recovering the power of exten- 
 sion is rendered greater. 
 
 The distinction, which Boyer, in his lec- 
 tures on the bones, has thought proper to 
 make, with respect to anchylosis, is very 
 singular and irreconcileable with our notions 
 on the subject ; for he distinguishes it into 
 dry and suppurating; but the latter, he 
 says, is a symptom of white-swelling. This 
 writer observes, that " anchvlosis is seldom 
 *' a primary disease, it almost always suc- 
 " ceeds another complaint." The direc- 
 tions to place the limb in that position, 
 which will render it, on recovery, the most 
 useful, should be obeyed under every cir- 
 cumstance, whether joints are likely to be- 
 come anchylosed by accident or disease. 
 
( 45 > 
 
 The elbow and finger joints should be kept 
 bent, while the knee should be preserved in 
 a straight line. 
 
 When the finger-joints are diseased, and 
 the ends of the bones are heard to grate, it 
 is a proof that their cartilaginous surfaces 
 are absorbed : I have known them to have 
 been renewed, at least the part has reco- 
 vered, without any of its motion being im- 
 paired. In the larger joints I have seen 
 onlj one instance of recovery, and that was 
 in a case of disease of the knee ; the bones 
 could distinctly be heard to grate, conse- 
 quently the ends of the bones must have 
 been deprived of their cartilaginous cover- 
 ing. On moving the patella, in two or 
 three instances, a grating noise could be 
 heard, yet no anchylosis in any case took 
 place, but something like cartilage was pro- 
 bably restored, as no grating sensation was, 
 on the recovery of the patient, any longer 
 perceptible. 
 
 If the complaint has proceeded so far as 
 to erode the articulating surfaces of the 
 
( 46 ) 
 
 bones, it has been generally thought that, 
 if the disease was cured, anchylosis must 
 inevitably ensue ; but cases of diseased knees, 
 where the bones on being moved were evi- 
 dently found to grate, have been cured 
 without being anchylosed, and the grating 
 sensation has ceased to be discoverable. 
 These instances would lead us to conclude, 
 that, if surgical attention can succeed in 
 checking the farther progress of the disease, 
 the joint will recover its action, and be ren- 
 dered rigid or anchylosed in proportion to 
 the extent of the disordered state of the 
 parts that previously existed. 
 
 Patients are very frequently, in this dis- 
 oi*der, troubled with spasms of the affected 
 limb J and, in the case of white-swelling, it 
 has been conceived, that these spasms have 
 induced the patient to bend the joint, and 
 to keep it in that situation, in order to pro- 
 cure ease. It has been ascertained, that the 
 spasms attending a broken leg or thigh are 
 much diminished in their violence by a re- 
 laxed position of the limb ; but the conse- 
 quence of allowing patients a similar indul- 
 
( 47 ) 
 
 gence in this disease, will occasion such a 
 contracted state of the joint as ultimately 
 to render it almost useless. Indeed an at- 
 tention to this point is highly necessary, 
 as the spasms may be lessened by opium 
 and the application of leeches to the joint, 
 and they will entirely subside as the disease 
 advances towards a cure. The emaciation 
 of the limb, which frequently attends this 
 disease, has been considered as an unfavour- 
 able circumstance, and it is to be remarked, 
 that if the complaint has not been of any 
 long continuance, the limb will often regain 
 its natural size, not otherwise ; for though 
 it may recover a degree of plumpness, it 
 will never arrive to the bulk of the healthy 
 limb. Nevertheless instances of recovery 
 have occurred with a very useful limb, after 
 a tedious and long suppuration, though it 
 has continued in a reduced size as long as 
 the patient lived. 
 
( 48 ) 
 
 SECTION III. 
 
 ON WHITE SWELLINGS OF THE JOINTS. 
 
 Mr. benjamin bell presents a melan- 
 choly statement, when he asserts, that after 
 the disease is completely formed, it may, in 
 almost every instance, be considered as in- 
 curable. This may be the case in Scotland, 
 but we are much more fortunate in our 
 practice here, and as no notice has been 
 taken by Mr. Bell of the remedies adopted 
 by us in England for the relief of those 
 afflicted with white-swelling, it is reason- 
 able enough to account for the result of the 
 practice with us, and in the north, being so 
 very contrary, by the circumstance of the 
 difference of our curative means from those 
 employed by our neighbours. 
 
 Although it is impossible to. ascertain the 
 precise state of the parts connected with 
 
( 49 ) 
 
 the disease called white- swelling, yet to 
 the afflicted with this complaint, it may be 
 no small comfort to be informed, that the 
 mode of treatment is not attended with the 
 perplexity which persons might expect in 
 instances of disease, the precise nature of 
 which is not accurately known. 
 
 For, if the malady originates within the 
 bone, in its progress the cavity of the joint 
 becomes concerned ; that affected, the parts 
 exterior to it suffer. In this instance of 
 white-swelling the bones are carious, and 
 the affections of the other parts are the 
 consequence of their diseased state. In 
 those instances of this malady, in which the 
 ligaments become first affected, the bones 
 suffer in the progress of the complaint in a 
 secondary manner, by abrasion of their sur- 
 faces, as I have stated ; and their structure 
 is not otherwise changed. 
 
 In the white- swelling of the knee and 
 elbow-joints, the thigh-bone and humerus 
 are much more diseased than the bones to 
 
( 50 ) 
 
 which they are connected, so much so in 
 the knee case, that I have, from viewing 
 the tibia, after death, or amputation, found 
 so httle disease about it, that I imagined it 
 Was brought only into a morbid state by its 
 connexion with the joint. 
 
 I deemed it right to mark the distinction ; 
 yet while the disease is attached to the per- 
 son of the patient, I cannot assist the reader 
 in discriminating between the one and th^ 
 other species. 
 
 The few opportunities I have had of ex- 
 amining diseased joints, after death or am- 
 putation, certainly did lead me to conclude, 
 that the ends of the bones, connected with 
 the diseased joint, suffer in the like manner 
 with the bodies of the vertebra, when they 
 are attacked by scrofulous caries ; and this 
 conception of the complaint induced me to 
 hope, that a mode of treatment similar to 
 that which Mr. Pott, so happily for man- 
 kind, recommended in curvature of the 
 spine, would prove an effectual relief for this 
 species of white-swellings 
 
( 51 ) 
 
 After the progress of the disease is arrest- 
 ed, much time is required before the parts 
 can assume a state of health; and when 
 they have arrived at this state, before the 
 articulation can become useful and strong, a 
 considerable time must also elapse. 
 
 Two knee joints I removed contrary to 
 my declared opinion, but was over pre- 
 vailed, by the solicitations of the patients 
 and their friends, to perform the operation. 
 The recovering condition of the joint, as ap- 
 peared on examining the diseased parts, has 
 caused me greatly to regret my too easy ac- 
 quiescence with the desire of the patients, 
 and has produced an unchangeable resolu- 
 tion in my mind, never again to amputate 
 but in those cases in which the life of the 
 patient imperiously calls for the operation. 
 
 The condyles of the thigh bone in each 
 case were softened in their texture; that of 
 the tibia was of its natural firmness, though 
 the articulating surfaces of both bones were 
 deprived of their cartilaginous covering, and 
 were anchylosed by ossific union. 
 E 2 
 
( 52 ) 
 
 It must be obvious to every surgeon, from 
 the history of these cases, what a length of 
 time must be required to effect the neces- 
 sary changes from a diseased to a healthy 
 state, and for the removal of parts by ab- 
 sorption, w^hich are not only useless, but, 
 until taken away by the absorbents, retard 
 the recovery of the patient, either by ossific 
 union or a renewal of their cartilaginous 
 surfaces. 
 
 I have considerable objection to this gen- 
 tleman's adoption of the term rheumatic 
 white- swelling ; and, although I agree with 
 him that there are two varieties of the com- 
 plaint, yet I cannot assent to the statement, 
 that one arises from rheumatism, and the 
 other from scrofula. 
 
 Rheumatism has nothing to do with it ; 
 and I should the less object to the term 
 rheumatic white-swelling were it intended 
 to convey a distinction only, but it goes 
 further, as it creates a confusion which may 
 prevent the patient's thinking seriously of 
 the imminent danger likely to follow from- 
 
( 53 ) 
 
 •an active inflammation attacking a large 
 joint. N 
 
 The terms I have thought proper to 
 adopt, in heu of those used by Mr. Bell, 
 are acute and chronic v^hite-swelUng. 
 
 I have seen the varieties, mentioned by 
 that author, in patients who have evinced 
 other signs of a scrofulous habit than the 
 disease in the joint, therefore it would be 
 erroneous to say the one was scrofulous 
 and the other not. 
 
 It is impossible for me to ascertain the 
 reason why Mr. Bell chuses to insist upon 
 the term rheumatic white-swelling, but, in 
 justice to this gentleman, I ought to notice 
 that other authors* have adopted the lik^ 
 terms. My researches have led me to this 
 conclusion, that in almost every instance 
 of the complaint, which has fallen under 
 my consideration, the patients have not 
 manifested any thing like a rheumatic dis- 
 
 * Boyer on Diseases of the Bones, and Cooper in his Sys- 
 tematic Surgery, 
 
{ 54 ) 
 
 position. This author is extremely just in 
 making the discrimination he has done be- 
 tween the two species, and the call for more 
 active exertions in the one instance than in 
 the other ; and this distinction meets with 
 my fullest concurrence, as respects the pro- 
 priety of the treatment. 
 
 But I cannot agree with him when he 
 says, that in the one, namely, the rheu- 
 matic, we may frequently accomplish a 
 cure; while in the other, the scrofulous, no 
 material advantage is to be looked for from 
 any remedy with which we are acquainted. 
 
 Were I to choose between the two spe- 
 cies of the disease, with the view of per- 
 forming a cure, I would select what I have 
 denominated the chronic white- swelling, 
 persuaded that the more time will be given 
 to treat the complaint judiciously, while 
 the other demands the most prompt and 
 active measures for its relief. In the acute 
 white- swelling the consequences which re*- 
 gard the health are more immediate and 
 serious, as the acute more rapidly advances 
 
( 55 ) 
 
 to the suppurative stage of the disorder. In 
 this we must first employ such remedies as 
 have a tendency to lov^er the constitutional 
 stimulus excited by the disease, before we 
 can expect the complaint to yield to local 
 measures. 
 
 I do not mean to say that constitutional 
 treatment is generally required in the ma- 
 jority of cases, but I have taken blood at 
 one time from the arm to the quantity of 
 4202;. before ease was obtained, or the feve- 
 rish disposition subdued. This patient had 
 previously, within the space of three or four 
 days, been twice cupped; 1202;. of blood 
 were abstracted at each operation; 2002;. 
 also were taken from the arm, and a num- 
 ber of leeches were constantly applied to 
 the joint every day. This young gentleman 
 was of a scrofulous habit ; he had often, at 
 different times, rheumatic pains flying about 
 him. His father, on seeing the joint, de- 
 clared that the complaint was not rheuma- 
 tism, but one which demanded the most 
 serious attention. This gentleman, although 
 a very excellent practical surgeon, did me 
 
( 56 ) 
 
 the honor of requesting my attendance upon 
 his son. We never saw a case attended with 
 more violent inflammation, a considerable 
 quantity of fluid was eflused within the ca- 
 vity of the joint, but which was absorbed 
 with the aid of one bhster, which was al- 
 lowed to heal up, and no other application 
 than cloths wrung out of the aqua ammo- 
 nias acetatae applied cold, and removed as 
 frequently as they lost their chill; for so 
 soon as the part became heated a painful 
 state of the joint occurred. 
 
 In this patient's case it is strikingly 
 evident, if a very early discrimination of 
 the nature of the disease had not taken 
 place, and the most active treatment been 
 spiritedly persevered in, that either his life 
 or his limb would have been lost; instead 
 of which melancholy termination, very little 
 inconvenience is the result, as there is no 
 other remains of the disease than a want of 
 power completely to straighten the limb, 
 but which is no drawback to the strength 
 of the joint, nor any abridgment of the ac- 
 tivity of its motions. 
 
( 57 ) 
 
 From some extracts from the late Mr. 
 Hunter's Lectures, in my possession, on 
 the subject of white-swelling, are contained 
 these remarks : "Its beginning and progress 
 '^ is generally similar to other scrofulous 
 " cases, stealing upon the part, occasioning 
 " stiffness, &c. There is some times fluc- 
 " tuation with pain, but then it is not truly 
 " scrofulous; the pain is sometimes scarcely 
 " perceivable, at other times considerable. 
 " They are of two kinds ; one is truly 
 " scrofulous ; the other, common inflam- 
 " mation, mixed with scrofula ; the latter, 
 ^' terminating in adhesion and suppuration." 
 Here are two species clearly pointed out by 
 this teacher ; and although he makes no 
 comment on the propriety of treating these 
 varieties, yet a surgeon must be very defi- 
 cient who cannot supply that want, after 
 having become acquainted with Mr. Hun- 
 ter's notions of the complaint. I do regret 
 that the above are the only observations on 
 the subject of white-swelling contained in 
 the manuscript I possess, yet 1 feel a plea- 
 sure in inserting them into the body of my 
 work, as remarks of much practical utihty. 
 
( 58 ) 
 
 I consider myself as fortunate in having it 
 in my power to produce such testimony 
 that I am not singular in my opinions, and 
 that they are founded on actual observation. 
 With regard to treatment, the antiphlogistic 
 plan must be resorted to according to the 
 degree of painful symptoms, and the ef- 
 fects they produce on the health of the pa- 
 tient. 
 
( 59 ) 
 
 SECTION IV. 
 
 ON THE ANDVANTAGES OF LOCAL BLEEDING IN 
 THE CURE OF WHITE-SWELLING. 
 
 X Cannot explain the reason why such con- 
 trary opinions should prevail with writers 
 on any subject of surgical disease, except by 
 supposing that some may make their state- 
 ment from what they think they know, and 
 not from what they have actually seen. This 
 circumstance may, I believe, in some in- 
 stances be the cause of such variety of sen- 
 timent; or, if this be not the case, it is 
 probable that the real state of the patient's 
 health, and of the disease must be a secon- 
 dary consideration, and be made subservient 
 to some theoretical view of the subject, 
 which the ingenuity of the author may 
 have thought proper to espouse. 
 
( 60 ) 
 
 A writer* of Dissertations on White- 
 Swelling observes, that " this complaint is 
 " always dependent upon debility, or lan- 
 " guid and morbid actions." In another 
 place he informs his reader, that the state 
 of the patient's strength will at no time ad- 
 mit the loss of one drop of blood, and 
 therefore, in proportion to the quantity ab- 
 stracted the patient must be weakened. 
 
 " The pathology of the pain," says the 
 same author, " is just the very reverse of 
 " what has been supposed; it is the off- 
 " spring of passive instead of active inflam- 
 " mation ; it is the necessary effect of de- 
 " rangement, debility, and morbid action; 
 " it is not the offspring of active inflamma- 
 " tion, because the deranged and scrofulous 
 " body does not, nor cannot, admit of this 
 " kind of inflammation. 
 
 " Were the pain of white-swelling caused 
 " by active inflammation, it would be most 
 
 * Dissertations on White-Swelling of the Joints, and the 
 Doctrine of Inflammation, by John Herdman, M. D. Fellow 
 of the Royal College of Surgeons of Edinburgh. 
 
( 61 ) 
 
 " severe at the very commencement of the 
 " disease v^hen the body is most vigorous, 
 *' and before it is v^orn out w^ith pain and 
 " morbid irritation; but the pain is seldom 
 " the first symptom, at least it is rather a 
 " dull than an acute pain, w^ith a sense of 
 *' general languor and w^eakness in the dis- 
 *' eased limb. As the other symptoms in- 
 */ crease, however, so also does the pain; 
 *' as the body becomes v^orn out and ema- 
 " ciated, as the force of every function is 
 ^' diminished, the pain becomes more and 
 *' more severe; and it is only the bursting 
 " of abcesses, the removal of distension and 
 ** irritation, that brings any relief from this 
 '* most acute and grievous pain/* 
 
 My own experience of the complaint will 
 not allow me to accede to the above con- 
 clusions, for, as I have pursued with great 
 activity the antiphlogistic treatment, which 
 Mr. Bell has recommended, I think I 
 must have witnessed its unsalutary ten- 
 dency ere now. I spoke of the advantages 
 of local blood-letting in my former publica- 
 tion, and my subsequent practice has fur- 
 
( 62 ) 
 
 ther satisfied me of its great utility. We 
 may object to the term rheumatic, but still 
 Mr. Bell is correct as to his notions of 
 there being two varieties of white-swelling, 
 which I have denominated the acute and 
 the chronic. Having noticed the above 
 passages from Dr. Herdman's Dissertations, 
 I shall add, that we must entertain very dif- 
 ferent views of this complaint ; and if his 
 are deduced from practical observation, I can 
 only say, that my opportunities of observa- 
 tion have not led me to consider the disease 
 in the same point of view which the Dr. by 
 his writings, has laboured to establish. 
 
 With respect to the advantage of local 
 bleeding in the generality of cases of white- 
 swelling, and even of phlebotomy in some 
 instances of the complaint, in which very 
 active inflammation has taken place, I can 
 appeal to many patients w^ho have received 
 the greatest benefit from this mode of treat-r 
 ment. Local bleeding should always be 
 first resorted to, and continued for a length 
 of time, until obvious improvement in the 
 joint takes place by a reduction of the swel- 
 
( 63 ) 
 
 ling and a releasement from pain. Weeks, 
 nay months have past, with obvious amend- 
 ment, and nothing else has been done but 
 cupping the joint, the repeated application 
 of leeches, and the continued use of cold 
 saturnine applications. 
 
 Mr. Cooper, in his first lines of the 
 Practice of Surgery, has noticed the dis- 
 tinction pointed out by Mr. Bell : he says, 
 " while-svv^ellings, v^hether of that descrip- 
 *' tion which has been termed rheumatic, 
 '' or that w^hich is denominated scrofulous, 
 '* present themselves in practice in two 
 " very different stages : in one, there is a 
 *' degree of acute inflammation about the 
 '* joint: in the other the affection is merely 
 *' chronic.'* That this complaint is occa- 
 sionally attended with acute, and with chro- 
 nic inflammation, is ver}^ certain, and in pro- 
 portion as the complaint partakes of the one 
 or other character it is obvious that the an- 
 tiphlogistic treatment should be more or 
 less actively employed. In the acute disease 
 of the joint, topical bleeding is insufficient, 
 »nd bleeding from the system should also 
 be had recourse to. 
 
( 64 ) 
 
 I am surprised that this writer should en- 
 tertain an opinion that there exists any such 
 disease as a rheumatic white-swelling : it is 
 well known that in acute rheumatism the 
 joints become swollen, and fluid is effused 
 into their cavity, but still these cases have 
 never been considered or termed white- 
 swellings. In these instances the com- 
 plaint is not confined to a single joint, but 
 several are affected at the same time, a cir- 
 cumstance which very rarely happens in 
 white-swellings. 
 
 The distinction made by Mr. Bell is there- 
 fore the more exceptionable, as tending to 
 impress on the minds of students two ma- 
 ladies very different from each other. The 
 observations which my own practice has 
 supplied, confirm the opinion of Mr. Hun- 
 ter, that white-swellings of the joints are in 
 fact scrofulous diseases, but that they may 
 be attended with either acute or chronic 
 inflammation. Mr. Cooper and myself es- 
 timate the use of the antiphlogistic treat- 
 pient very differently; he observes, "topical 
 *' bleeding and cold saturnine lotions are 
 
( 65 ) 
 
 ' certainlj indicated when acute inflamma- 
 ' tion is present, and what is imphed by 
 ^ the antiphlogistic treatment may now be 
 ' advantageously employed. I cannot with- 
 ^ hold my censure from those practitioners, 
 ' who lose weeks and months in the adop- 
 
 * tion of such treatment. The plan is truly 
 ' useful as long as the integuments are hot 
 ' and tender, and there are symptoms of in- 
 ' flammatory fever ; but no sooner is this 
 ' stage past than such treatment is ridicu- 
 ' lously inert, and by preventing the em- 
 ' ployment of really efficacious measures, 
 
 • it may even in some degree be conducive 
 ' to the encrease of a most terrible dis- 
 ' ease." I wish to impress on the stu- 
 dent's mind the circumstance that, the in- 
 teguments are not originally diseased but 
 become affected sympathetically, and that 
 only in the more advanced periods of the 
 complaint. Even when the patient does ex- 
 perience considerable uneasiness within the 
 joint, which is greatly aggravated by exer- 
 cise, the integuments can still be made to 
 slide freely over its surface, and will be found 
 not in the least tender to the touch, and of 
 
 F 
 
, ( 66 ) 
 
 their natural temperature. I caution the 
 practitioner against drawing his conclusion 
 of the actual condition of the internal cavity 
 of the joint from the state of the parts with- 
 out, if he should be so unfortunate as thus 
 to make his deduction, I know from mj 
 own experience, 9s well as from that of 
 others, that he will find himself deceived, 
 and his treatment will be deservedly im- 
 pugned as lamentably inefficient. 
 
 Whether this gentleman writes from his 
 ow^n experience or from having witnessed 
 the practice of others, I have enjoyed equal 
 opportunities, and shall be honored by any 
 student or practitioner in surgery calling 
 upon me for a reference to cases in which 
 I have employed the antiphlogistic treat- 
 ment with great energy, and the best pos- 
 sible success. 
 
 Since the publication of my Practial Ob- 
 servations on Diseases of the Joints, I have 
 had abundant reason to conclude, from the 
 successful termination of several cases, 
 which have since been placed under my 
 
( 67 ) 
 
 care, that so far from having persevered too 
 much or too long in their treatment by cup- 
 ping and applying leeches frequently to the 
 joint, that I censure myself for not having 
 employed local bleeding, in the cases which 
 I. had previously published, to the same ex- 
 tent and with the same energy which is 
 now my invariable practice. 
 
 It is of the highest importance that the 
 integuments, covering a diseased joint, be 
 preserved in as healthy a state as possible, 
 but to wait until they become inflamed and 
 painful to the touch, is an act of unpardon- 
 able supineness. To remove the disease 
 w ithin the articulation, and to prevent the 
 external parts becoming affected, cannot be 
 more certainly accomplished by any means, 
 than by the abstraction of blood by the 
 means of cupping and leeches, together 
 with the application of cold washes ; and 
 when the patient has derived all the be- 
 nefit obtainable from these methods, a 
 purulent drain may be afterwards establish- 
 ed with greater expectation of recovery. 
 
 F 2 
 
( 68 ) 
 
 If Mr. Cooper means by really efficacious 
 measures, the application of blistering plas- 
 ters, and dressing the surface, after the 
 cuticle is removed, with the savine cerate, 
 or establishing caustic issues on each side 
 of the diseased joint, I congratulate myself 
 as having been the means of ascertaining 
 the salutary eiFect of this treatment, and of 
 having communicated the result of my 
 practice to the profession. 
 
 We ought to have in vievi^ two objects in 
 recommending local bleeding for the relief 
 of this complaint: the one is, to remove 
 the inflammation existing within the arti- 
 culation ; the other, to prevent the bane- 
 ful effects of inflammatory attacks which 
 may invade the external coverings of the 
 joint in the progress of the disease. In 
 my former publication are the following re- 
 marks on the efficacy of local bleeding: 
 
 The advantages of local bleeding, as a 
 means of relief in this complaint, merit our 
 attention, though it has not appeared of any 
 service, except in cases attended with pain : 
 
( 69 ) 
 
 dn these, it is proper, that the part should 
 be bled largely and repeatedly, until the 
 patient's sufferings are somewhat mitigated. 
 It has not appeared to me, that this treat- 
 ment alone has ever entirely removed the 
 pain, much less cured the disease. In one 
 case, indeed, where no other means were 
 adopted, the patient became easier for a 
 short time, but in a few w eeks the pain re- 
 turned with its former severity, and the 
 progress of the complaint seemed to have 
 received only a temporary check. 
 
 I have however witnessed the efficacy of 
 local bleeding, in cases of violent pain with- 
 in a joint, unattended with swelling. All 
 the patients thus affected were of a scrofu- 
 lous habit. In addition to this treatment, 
 the perspiration of the part was kept up 
 by fomentations and poultices ; the patients 
 were confined to bed, the state of their 
 bowels attended to, and antimonial prepa- 
 rations, assisted by a quantity of opium, 
 proportioned to the degree of pain and age 
 of the patients, were administered in the 
 evening. I have known this method of 
 
( 70 ) 
 
 treatment completelj succeed in removing 
 an incipient complaint, which, if suffered to 
 proceed, would most probably have termi- 
 nated in white- swelling. 
 
 I may warrantablj presume, that when 
 these opinions were imparted to the public, 
 they were founded on -practical obser- 
 vation, but impressed, as my mind must 
 have been at the time, with the superior 
 efficacy of drains, it is not surprising, that 
 I did not ascertain to what extent local 
 bleeding would have been beneficial. 
 
 Were cases, exactly similar to those I 
 have published, now to come under my 
 care, I am satisfied, that abstraction of blood 
 from the part would be pursued with greater 
 vigour. Experience, and not theory, has 
 led me to follow up the antiphlogistic plan 
 as long as any benefit can be received by 
 this mode of treatment. 
 
 When I have employed irritating means, 
 without previous or sufficient local bleeding, 
 my mistake has become too obvious ; for I 
 
( 71 ) 
 
 have been obliged, in consequence of the 
 pain, which has existed within the joint, to 
 heal the bhstered surface, and proceed in 
 the cure precisely after the manner which 
 I have just recommended. 
 
 In a conference I had with Mr. Aber- 
 NETHY some years since, he informed me, 
 that he inculcated in his lectures the doc- 
 trine of not resorting to the use of irritants, 
 until the antiphlogistic treatment had been 
 fairly tried. In justice to this excellent 
 teacher, it is but right to acknowledge, that 
 this conversation led me to employ local 
 bleeding more energetically, the advantage 
 of which practice has been conspicuously 
 useful; for, since adopting it, I have not, 
 when I considered it a proper time to es- 
 tablish a permanent drain, met with the 
 interruption I before experienced from sub- 
 sequent attacks of inflammation. 
 
 It is obvious, that leeches must be used 
 in those cases, in which, from the swelling 
 of the joint, the integuments are in a state 
 of tension, and that they are also to be pre- 
 
( 72 ) 
 
 ferred when the skin is inflamed. These 
 are the only circumstances, under which 
 this mode of drawing blood is preferable to 
 another, for the benefit to the patient has 
 been always in proportion to the quantity 
 of blood removed, and has not been at all 
 influenced by the manner of its removal. 
 
 To avoid repetition of cases, so nearly 
 resembling each other, I shall only an- 
 nounce the recovery of a very bad diseased 
 knee, and as its appearance was novel, it 
 might be worthy of the reader's attention. 
 The tibia was unaffected, but the end of 
 the thigh bone, which articulated with it, 
 although the case has been long cured, re- 
 mains much reduced in its size, and mani- 
 fests no appearance of condyles. 
 
 It is an admirable instance of the efficacy 
 of purulent drain, which was maintained by 
 blistering the part, and the application of 
 the savine cerate. This patient was scro- 
 phulous, but she received considerable relief 
 from repeatedly applying several leeches, 
 previously to the application of the blister. 
 
( 73 ) 
 
 and which were also often required to allay 
 occasional irritation, which manifested itself 
 during the maintenance of the discharge. 
 
 I lately took Mr. Lawrence to see a knee- 
 joint, "which had remained under my treat- 
 ment for four years ; the patient has recover- 
 ed, but with a stiff joint occasioned by ossific 
 union. I had more interruption in the ma- 
 nagement of this complaint than usual, for 
 repeated attacks of inflammation occurred 
 during my attendance, to relieve which, the 
 patient, a female, was occasionally cupped, in 
 the whole ten times, and twelve ounces of 
 blood were abstracted at each operation, be- 
 sides the application of four hundred leeches, 
 most of which were repeatedly made use of. 
 As soon as ] thought the diseased part was 
 brought into a quiet state, I blistered the 
 joint, and kept the part discharging, by 
 means of the savine cerate; but in a few 
 days I was obliged to heal the surface, to 
 remove the irritation which was produced : 
 I then directed the repeated application 
 of several leeches, and when the inflamma- 
 tion had subsided, caustic issues the size of 
 
( 74 ) 
 
 a crown-piece were established on each side 
 of the knee by the apphcation of the paste 
 caustic. 
 
 I have just completed another cure of a 
 diseased knee, which had been bad above 
 twelve months, and by a surgeon was sup- 
 posed to be rheumatic gout. This young 
 person was of a scrophulous habit, having 
 had a strumous gland on one of her breasts, 
 which dispersed, and was by a female em- 
 pyric said to have been cancerous. The 
 ease and reduction of the swelling of the 
 joint, w^hich were obtained by the means of 
 cupping and leeching, were very remark- 
 able. A blister was afterwards applied on 
 each side, and the surface kept open by a 
 dressing of the ceratum sabinae for about 
 three months, during which period half a 
 dozen leeches were frequently employed. 
 However highly I may think of artificial 
 discharges in the cure of diseased joints, yet 
 I cannot too strongly recommend the adop- 
 tion first of the antiphlogistic treatment and 
 cold evaporating washes to the part, so long 
 as any benefit seems to be derived from 
 
( 75 ) 
 
 their use. I ought to state that this young 
 lady's health received considerable improve- 
 ment during the cure. Since v^riting the 
 above, 1 felt a very strong inclination, 
 which was enforced by a sense of public 
 duty, to pay a visit, where it was possible, 
 to such persons whose cases were published 
 in a former edition. 
 
 A case recorded by me as of a joint cured, 
 and only left increased in size by the ex- 
 pansion of the ends of the thigh bone, 
 turns out, on an examination which took 
 place this day,* to be the very reverse, for 
 it is smaller than the other, across the con- 
 dyles, above an inch. This patient was 
 treated by caustic issues, and I shuddered at 
 the risk to which 1 had exposed the patient, 
 for the eschars were situated on each side 
 of the joint, so that their extent equally 
 embraced the tibia as the femur. The in- 
 teguments covering the inner condyle had 
 precisely that appearance we observe in ill- 
 performed amputations, in which a renewal 
 of skin becomes the only covering of the 
 
 * October 25, I8O7. 
 
( 76 ) 
 
 projected bone. I might in this instance 
 have indulged myself with a little theory, 
 and imagined that during the continuance 
 of the complaint the natural progress of 
 growth in a child might, in a diseased 
 joint, be impeded, but admitting this re- 
 mark to have due weight, still nothing else 
 than the disease in the bone could account 
 for its altered figure. I confess that out- 
 ward examination led me first to the con- 
 clusion, that the ends of the bones were 
 expanded, but the result of this case has 
 satisfied me that I must have adopted this 
 opinion in consequence of the deceitful feel 
 communicated through the diseased exter- 
 nal covering of the joint. 
 
 Hence it may fairly be inferred, that 
 the diseased and thickened condition of the 
 parts, situated externally to the joint, was a 
 sufiicient protection to secure it against any 
 possible injury which the application of 
 the kali purum might otherwise have ef- 
 fected. 
 
 1 am inclined, from having inspected 
 
( 77 ) 
 
 other joints, which I, in mj former publi- 
 cation on this subject, reported as having 
 left rather enlarged in consequence of, as I 
 imagined, a tumefied state of the bones, to 
 believe I must have been mistaken, as they 
 do not appear in the least increased in their 
 size ; and the efforts of nature, it is clearly 
 ascertained, will be of itself sufficient to 
 remove any slight thickening of parts w^hich 
 might remain after the disease has been 
 considered as cured. 
 
( 78 ) 
 
 SECTION IV. 
 
 ON THE SUPPURATIVE STAGE OF WHITE-SWEL- 
 LING. 
 
 feuppuRATioN occurring in white- swelling, 
 if confined to the parts exterior to the ca- 
 vity of the joint, now and then affords re- 
 lief, arrests the progress of the disease, and 
 in some instances effects a cure. I wish I 
 could say that this mode of termination 
 was the general consequence of suppura- 
 tion, but the reverse is almost always the 
 case ; for, when the disease is approaching 
 to this state, the patient's health begins to 
 suffer, and the degree of danger is rendered 
 more imminent by different abscesses form- 
 ing, the irritation and discharge of which, 
 independently of the mischief that is occa- 
 sioned to the integuments and other parts 
 of the joint by extensive ulceration, has 
 
( 79 > 
 
 sometimes rendered it necessary that the 
 patient should submit to amputation. 
 
 T have taken every opportunity to inform 
 myself as to the propriety of opening the 
 different abscesses which occur in this dis- 
 ease, and am satisfied that this practice, 
 so far from being productive of advantage, 
 has greatly increased the inflammation, and 
 extended the sloughing of the soft parts; 
 in some instances it has even produced ul- 
 cers of the phagedcenick kind, whilst in 
 others, diseased fungi have sprung up. 
 
 Dilatation of the openings, spontaneously 
 formed, has been recommended with a view 
 to expose caries, and facilitate the exfolia- 
 tion of the diseased bone ; but should the 
 introduction of a probe into any of these 
 sores discover the bone to be affected, it has 
 seemed good practice, under such circum- 
 stances, to forbear the use of the caustic or 
 knife, and not, as Mr. Bromfield has di- 
 rected, to enlarge them; as he himself says, 
 the carious part will crumble away insensi- 
 bly, and be discharged with the matter. 
 
( 80 ) 
 
 When ulcers have been produced of the 
 ill-conditioned kind, just mentioned, there 
 has excited for a length of time a morbid 
 state of the soft parts, and that to a greater 
 extent than often could be expected from 
 the appearance of the skin. 
 
 Even where ulceration has happened in 
 an earlj stage of w^hite-swelling, though 
 the sores are certainly not of that malignant 
 nature just described, yet from their num- 
 ber (for as soon as one heals another breaks 
 out) they v^ill constitute a more extensive 
 disease of the integuments than may have 
 been imagined, and the circumstance of the 
 cellular membrane being destroyed will ren- 
 der the healing of them very difficult; they 
 sometimes indeed do heal, but then they 
 generaly break out again, or fresh ulcera- 
 tions are formed in parts contiguous to the 
 former. 
 
 Practice, and not hypothesis, inclines me 
 to condemn the dilatation of the sores which 
 are produced in this complaint; for till I 
 was satisfied of the inconvenience which 
 
( 81 ) 
 
 which occurs from the use of the knife, I 
 was in the habit of laying them open. I 
 can mention more than one or two cases, 
 in which fungus arose after extensive open- 
 ings which had been made ; and the same 
 effect I have known to occur in abscesses, 
 which have burst, with a considerable 
 sloughing of the skin. 
 
 Extensive inflammation has also followed 
 the use of the knife, under the above-men- 
 tioned circumstances, and from some cases, 
 I shall select the following instance of the 
 ill effects of such operation. A patient had 
 a white-swelling of the knee in which a 
 number of collections of matter had form- 
 ed, but as it was confined, and the different 
 abscesses were found by the probe to com- 
 municate with each other, there were hopes 
 that, by dilating the most dependent to an 
 extent of not more than half an inch, I 
 should be able to effect a complete dis- 
 charge of the matter. This was accordingly 
 done, and on seeing the patient the day fol- 
 lowing I found him very feverish ; he com- 
 plained of violent pain over the whole knee, 
 
 G 
 
( 82 ) 
 
 and within the joint, which was prodi- 
 giouslj enlarged by the inflammation which 
 had supervened. The irritation and th© 
 great discharge, during only a few days, 
 had so reduced him, that amputation was 
 proposed as the only means of saving his 
 life, to which he would not submit, and 
 within three weeks he died hectic. 
 
 It would seem that the opening alone 
 occasioned these evils, by inducing irrita- 
 tion on parts in a state of disease, and 
 thereby augmenting rather than alleviating 
 the disorder. 
 
 Patients do not sometimes apply for sur- 
 gical relief till suppuration has advanced ; 
 ^nd then it is generally encouraged by the 
 application of warm fomentations and poul- 
 tices, from a notion, as I suppose, that it is 
 improbable that discussion can be obtained 
 under such circumstance. But I have re- 
 peatedly succeeded in effecting the absorp- 
 tion of a fluid, which I had previously as- 
 certained to be pus, from every attending 
 circumstance, such as the appearance of the 
 
( 83 ) 
 
 skin, the degree of pain endured, and par- 
 ticularly when the part was examined, to- 
 gether with the general state of the pa- 
 tient's health. 
 
 Though the complaint has sometimes 
 been cured by the occurrence of abscess 
 in parts exterior to the joint, yet the situa- 
 tion of such patients has been rendered very 
 hazardous, for it is great good fortune if 
 they are not destroyed by the irritation and 
 drain of these sores, and I have seen the 
 removal of the limb become a necessary 
 consequence of such external abscesses. 
 
 White-swellings occasionally recovering 
 after the suppurative stage of the disorder, 
 is an occurrence which has often given cre-^ 
 dit to remedies of no real utility. For if the 
 patient should possess strength sufficient to 
 support him under the discharge, the last 
 application as well as the last practitioner 
 who attended, will appear to have the me- 
 rit of curing the disease, the patient not 
 being apprized that this is sometimes ef- 
 
 G 2 ' 
 
( 84 ) 
 
 fected by the spontaneous formation of an 
 abscess. 
 
 No surgeon, possessing humanity or judg- 
 ment in his profession, would, in a case of 
 curvature of spine, arising from a diseased 
 ;§tate of the vertebrae, recommend his pa- 
 tient to wait for the appearance of lumbar 
 abscess, because, perhaps in one instance a 
 cure has supervened, but would imme- 
 diately advise the caustics, from a convic- 
 tion that it is almost a certainty that even 
 if such abscess should take place his patient 
 would be drained to death, in consequence 
 of the great and long continued discharge. 
 
 And though it has been observed that 
 =where suppuration has taken place, and an 
 external abscess been formed, in the early 
 istage of white- swelling, a final cure has 
 pccasionally folio wed ; it should nevertheless 
 be remembered, that this abscess had no 
 connexion with the cavity of the joint, for 
 if it had, the chance of the patient's reco- 
 very would have been extremely preca- 
 rious ; and where it happens that the coi»- 
 
( 85 ) 
 
 plaint has proceeded so far as thoroughly 
 to disorder every part connected with the 
 joint, even in that case the formation of 
 abscess becomes an unfortunate occurrence, 
 as tending to increase the complaint and 
 exhaust the patient. 
 
 Should it be deemed advisable to remove 
 a limb, under the circumstance of matter 
 being collected in a considerable quantity 
 underneath the integuments, it had better 
 be discharged by puncture a few days before 
 the operation be performed. 
 
 I was present at an amputation above 
 knee, in which the operator neglected this 
 caution, and when he made his first inci- 
 sion down to the muscles, he discharged a 
 large quantity of matter, and the appear- 
 ance of the stump, from the retraction of the 
 integuments, did not promise, what actually 
 turned out to be the case, a speedy recovery. 
 
 A gentleman was wounded in a duel ; the 
 ball passed through the joint of the knee ; ark 
 attempt was unfortunately made to save the 
 
( 86 ) 
 
 limb; however amputation was at last had 
 recourse to, under circumstances exactly si- 
 milar to the preceding case ; the integuments 
 greatly retracted, and the stump, as might be 
 imagined, was very ill-formed. 
 
 This case terminated more unsuccessful- 
 ly, as it was attended with considerable ex- 
 foUation. The operation was performed 
 abroad, and I was consulted on the state of 
 the stump on his return to England. 
 
 The retraction of the integuments was a 
 very unfortunate occurrence, which might 
 most probably have been prevented had they 
 been relieved of the matter by puncture, 
 and sufficient time allowed the parts to re- 
 cover themselves. Had this treatment been 
 adopted, I think it pretty certain that the 
 patients would have been more largely in- 
 debted to their respective surgeons for their 
 cure. 
 
 The efficacy of artificial purulent dis- 
 charges, in cases of diseased joints, in which 
 matter had formed, has been fully exempli- 
 
( 87 ) 
 
 fied by the cases which I have already pub- 
 lished; my practice since would have en- 
 abled me to add to them, but a higher gra- 
 tification is reserved for me by the inser- 
 tion of the practical remarks conveyed to 
 me by Mr. Ward in the subsequent letter. 
 This gentleman, although a stranger, has 
 laid me under a lasting obligation, and has 
 reflected the highest honor upon himself, as 
 taking an interest in the welfare of man- 
 kind, by communicating his opinions to me. 
 Had his example been generally followed 
 by other professional men, it might not have 
 called from me such marked approbation of 
 that sense of public duty, with which, I am 
 sure, his mind must have been impressed 
 when he honored me with his correspon- 
 dence. 
 
 Sir, 
 
 Since the publication of your Trea- 
 tise on White-Swellings, I have tried the 
 plan of treatment there recommended, in 
 the Manchester Infirmary, in cases which 
 could not otherwise have been benefited, 
 and with the best eiFects : I therefore think 
 
( 88 ) 
 
 it incumbent on me to inform you of the 
 success which has accompanied the prac- 
 tice, in several cases of white- sweUing of 
 the knee and elbow joints, where the ends 
 of the bones were enlarged, a fluctuation of 
 matter was very evident, and the least mo- 
 tion of the limb was attended with consi- 
 derable pain. 
 
 The amendment in the general health of 
 the patients, during the continuance of the 
 discharge, was very remarkable, and I am 
 confident I have in this way saved limbs, 
 which must otherwise have been ampu- 
 tated. 
 
 I am. Sir, 
 
 Your very humble Servant, 
 M. WARD. 
 
 Manchester, Aug. 8, 1799. 
 
( 89 ) 
 
 SECTION VI. 
 
 ON THE TREATMENT OF FUNGOUS EXCRES- 
 CENCES IN white-swellings' OF THE 
 JOINTS. 
 
 W ISEMAN has succeeded in the cure of 
 several diseased joints, and he has also failed 
 in the treatment of others, but from an im- 
 partial perusal of the history he gives of his 
 patients, it might fairly be imagined that his 
 failure was not a little attributable to the 
 unwarrantable and shocking practice of his 
 time of applying the actual cautery to the 
 internal cavity of a large joint. When the 
 Serjeant speaks of his patients dying tabid, 
 it is a matter of surprise that such a circum- 
 stance did take place, and that it was not pre- 
 vented by the intervention of locked jaw and 
 tetanus. We will now take a view of his 
 successful cases ; in these we shall find that 
 the complaint did not afford him an op- 
 portunity of using the same treatment to 
 
( 90 ) 
 
 the like extent, for the external openings 
 did not communicate with the joint. The 
 uhimate success, attending his apphcation of 
 caustic to the different collections of matter, 
 which formed under the integuments, can- 
 not be doubted, if we only advert to the 
 success attendant on caustic issues, although 
 it be true that Wiseman made his eschar 
 on diseased parts, whereas, modern surgery 
 makes choice of sound integuments for the 
 application of the caustic. 
 
 My determined opposition to opening col- 
 lections of matter, formed externally to a 
 diseased joint, has in many cases been pro- 
 ductive of benefit, for it has frequently been 
 absorbed entirely, and in all other instances 
 considerably discussed. This resolution I 
 am convinced has saved my reputation a few 
 times, when, had I been busy with knives 
 or caustics, it would have occasionally suf- 
 fered; for I confess having seen some cases, 
 which from examination, the violent throb- 
 bing pain in the part, the inflamed state of 
 the skin, together with the feverish condi- 
 tion of the patient, left no doubt in my 
 
( -91 ) 
 
 mind but that matter had formed. I made 
 a very small puncture in a part where I 
 thought fluctuation was most perceptible, 
 after w^hich not any thing escaped but a 
 drop or two of blood. In these cases the in- 
 teguments are unequally distended, which 
 in different parts are at length removed by 
 absorption, and large fungi thrust up in their 
 place. Wiseman has very candidly advised 
 that the practitioner should in such cases be 
 wary in his prognostic. I imagined that the 
 absorbents had removed the integuments, 
 because had they not been so disposed of, 
 I must have observed that they sloughed. 
 I have under my care at this time two cases 
 of the kind — they are of the ancle joint — 
 one of which I shewed to Mr. Lawrence, 
 for whose judgment I have a very high re- 
 spect, and it pleased me that he concurred 
 in my opinion, with respect to these fun- 
 gous exuberances. I am inclined to beheve, 
 from the improving state of these joints, 
 that no attempt for their reduction should 
 be made ; and, from what I have observed, 
 it is not improbable that they will subside 
 altogether as the disease advances towards 
 a cure. In caries we have already spoken of 
 
( 92 ) 
 
 the use which these granulating excesses 
 seem to possess ; and so important do I think 
 the result of the cases now detailed, in deter- 
 mining whether these fungi should be re- 
 garded as healthy processes for the removal 
 of diseased bone by absorption ; or whether 
 we are in future to view them in the light of 
 diseased appearances, as they have hitherto 
 been considered, that I shall state to the pro- 
 fession, through the channel of some peri- 
 odical publication, the successful or unsuc- 
 cessful termination of them. I lately met 
 with some MSS. of the late Mr. Else's, on 
 diseases of bones, in which, in pursuance of 
 old authority, he directs the fungous excres- 
 sences to be removed ere we can expect 
 exfoliation to take place. The former of 
 these ancle cases I had the other day 
 [Oct. 27] an opportunity of enquiring after, 
 it was six months since I quitted my at- 
 tendance on this patient, and although 
 obliged to me for my great attention, and 
 stating that no alteration in my mode of 
 treatment had taken place for some months, 
 it was wished that I should give way to 
 another's treatment, and a magnetic doc- 
 tress was chosen as my successor. I found 
 
( 93 ) 
 
 to my great satisfaction that the integu- 
 ments were healed, and the fungus sub- 
 sided, without the use of escharotics, or 
 the knife, and no exfoliation had occur- 
 !red; this joint also is smaller than the 
 other, and the malleolar end of the tibia is 
 „ evidently flattened. Had the dressings been 
 >a little varied from time to time, the pa- 
 tient's friends would, I am persuaded, have 
 been more contented ; and I do not know, 
 as emolument was no part of my conside- 
 ration in my attendance on this patient, 
 whether I should not have been justified in 
 such deception. The joint is weak, but he 
 is able to stand more flat on the foot, and 
 bear more weight. This doctress deserves 
 this commendation, that her applications, 
 like mine, if they did no good, were capa- 
 ble of no harm. 
 
 The circumstance of its having occurred 
 to me so very lately, that I might receive 
 some additional information in point of 
 practice, by calling on some of my former 
 patients, will, I hope, be accepted as an 
 apology for these remarks not appearing 
 in their proper place. 
 
( 94 ) 
 
 It is true that in this case these fungi dis- 
 appeared without the application of caustic 
 or the use of the knife, and I am inchned 
 to coincide in the opinion entertained by 
 Mr. Abernethy, in his account of fungi of 
 the dura mater. After the tumour is ex- 
 posed by the removal of the cranium which 
 covers it, he observes, " Although the de- 
 " struction of the fungus might be proper 
 " for the sake of expedition, and it can per- 
 " haps be attended with no harm by what- 
 *' ever means effected, yet it may not be 
 " necessary. Like other animal fungi it 
 '^ will cease to grow, and soon disappear, 
 " when the irritation which occasioned it 
 " has been removed."* It was this sentence 
 which excited my attention, there being 
 so much sound practical information con- 
 veyed in a very few words, and which may" 
 be applicable to all cases of fungous excres- 
 sences attended with carious bone ; but the 
 removal of the bone in fungi of the dura 
 mater becomes necessary from the peculiar 
 situation of the disease. 
 
 * Essa^ on Injuries of the Head^ p. 85. 
 
( 95 ) 
 
 SECTION VII. 
 
 ON THE EFFICACY OF COLD APPLICATIONS^ 
 WITH BRIEF REMARKS ON OTHER REMEDIES. 
 
 Presuming it unnecessary, it is there- 
 fore deemed improper, to occupy much of 
 the reader's attention, by a minute detail 
 of the apphcations usually employed for 
 the relief of this disease, especially as they 
 have proved unsuccessful, or from the de- 
 gree of their efficacy, can, at the most, only 
 be considered as palliatives. The effect of 
 cold, in suspending the progress of ulcera- 
 tion in the spina ventosa, vras noticed by 
 Rhasis. Cold applications of the aqua li- 
 thargyri acetati composita, or sal ammoniac, 
 during its solution in vinegar and water, 
 though possessing no curative power, have 
 had their use by checking inflammation, 
 and thereby retarding the progress of the 
 complaint towards suppuration, and conse- 
 
( 96 ) 
 
 quently preserving the integuments for a 
 longer time in a healthy state. These ap- 
 plications besides have sometimes effected 
 a slight reduction of the swelling of the 
 joint, by promoting absorption of some of 
 the fluid collected under the integuments ; 
 yet this is but a superficial advantage, for 
 this fluid vrill be re-produced, whilst the 
 progress of the disease, within the articula- 
 tion, is unimpeded. 
 
 The ease and benefit which the patient 
 always expresses as having obtained by the 
 constant use and renewal of cold appli- 
 cations to the joint, would, we should think, 
 preclude the surgeon from recommending 
 heated applications : I have witnessed their 
 effects, as directed by other practitioners as 
 well as being adopted by the suggestion of 
 the patient's friends. I cannot regard them 
 as harmless, in my opinion they have become 
 mischievous by encouraging suppuration, 
 and diseasing the integuments, which it 
 should be the surgeon's most anxious care 
 to preserve entire and unaffected. We shall 
 further notice the effect of heat when we 
 
( 97 ) 
 
 speak of hip-affection, which is a complaint 
 analogous to our present subject. 
 
 The application, usually termed white- 
 wash at the hospital, is an exceptionable 
 formula for a saturnine lotion, for the skin 
 as well as the cloths moistened with the 
 same, early become coated with the lead 
 which is always precipitated, if hard water 
 be used instead of that which has been dis- 
 tilled. Although the pharmacopeia of the 
 Royal College of Physicians of London, and 
 those of different hospitals, have directed the 
 latter to be used, economy may have been the 
 reason why common water has, in hospital 
 practice, been so generally substituted. 
 
 I am in the habit of using the following 
 form as one not liable to the above-men- 
 tioned objection. 
 
 R. Cerussse Acetatae 51, 
 Aceti di^tillati §ij. 
 Aquas distillatae §xiv. 
 
 Misce pro lotione. 
 
 Mr. AbernethTj I am told, recommends 
 
 H 
 
( 98 ) 
 
 tincture of opium considerably diluted with 
 water ; in short, water alone is preferable to 
 the application we have been objecting to : 
 a clean and not expensive epithem for the 
 poor, is one third of distilled vinegar to two 
 of water. 
 
 ON MERCURY, SEA AIR, AND BATHING. 
 
 Mercury was resorted to by Heister in 
 complaints of this nature,, from a notion 
 that they arose from a venereal taint. Not- 
 withstanding the success he attributes to 
 this medicine, it would appear, from the 
 observations I have been able to make res- 
 pecting it, or to collect from the experience 
 of others, that there is not the smallest 
 foundation for this opinion ; for, surely, if 
 there were any affinity in the nature of the 
 two disorders, the remedy which absolutely 
 cures the one would in some degree hjave a 
 tendency to relieve the other. 
 
 Patients labouring under white-swellings 
 have applied to me on account of venereal 
 complaints, which were entirely removed 
 
( 99 ) 
 
 hy mercury, whilst no effect was produced 
 on the diseased joint, even where the fairest 
 possible opportunity was given, by rubbing 
 it into the affected limb, which conse- 
 quently exposed the joint completely to its 
 action. 
 
 Mercurial friction has indeed in some 
 degree reduced the swelling of a joint, by 
 promoting absorption of fluid collected im- 
 mediately under the integuments; but, as it 
 had not any power over the disease, which 
 existed within the articulation, the tume- 
 faction returned. This mode of treatment 
 will sometimes succeed in curing that sort 
 of complaint which in appearance resembles 
 the true white-swelling, but the seat of this 
 disease is in the more external parts; it 
 must be seen how widely it differs from that 
 kind of affection which has its origin in a 
 distempered state of the ligaments, or of the 
 articular part of the bone. I have said, that 
 in such cases mercury sometimes succeeds, 
 but it will much oftener fail. 
 
 There is such an undecisiveness of cha- 
 H 2 
 
( 100 ) 
 
 racter attaching to surgical writers, as would 
 induce a stranger to the profession to ima- 
 gine that some practised in the air, where 
 man J, it is said, have erected their castles; 
 for I think, if all practitioners spoke of re- 
 medies only from actual experience of their 
 efficacy, it might be expected that we should 
 be a little better agreed. 
 
 On the use of mercury in white-sWelling 
 
 1 have selected the following observations : 
 
 *' In the first stages of the disease this mode 
 
 " of treatment seldom fails to prove useful; 
 
 ** local blood-letting, when carried to a suf- 
 
 " ficient length, very commonly relieves the 
 
 " symptoms induced by inflammation, and 
 
 *^* the blisters often remove them entirely, 
 " These remedies however are not to be 
 
 *' trusted in the more advanced stages of 
 
 *^ white swelling, nor ought they ever to 
 
 •' be long persisted in when they do not, 
 
 *' soon procure relief. In this state of the 
 
 " disease never depend upon other reme- 
 
 ** dies. Mercury proves here particularly 
 
 " useful, not given so as to salivate, but 
 
 " merely to affect the gums gently, and tp 
 
( 101 ) 
 
 " keep them in that state for a few weeks. 
 " In such circumstances the best method 
 *' of using mercury is by external friction; 
 *' and the unction should be of such a 
 '^ strength," (surely the author must have 
 intended weakness,) " as to admit of being 
 " used in the quantity of two drams three 
 ** times a day; for friction, in order to 
 " prore useful, should be frequently re- 
 -** peated, and continued for the space of an 
 ** hour each application."* 
 
 Although this author speaks very indefi- 
 nitely as to the quantity of mercury which 
 should be proportioned to the lard, yet it 
 should be remarked, that he has directed its 
 use until it has produced a constitutional 
 effect, and, even slightly as he might wish 
 to manage this mercurial process, my expe- 
 rience has ascertained its want of success ; 
 and in some cases I have observed, in which 
 a very gentle course of mercury has been 
 employed, that the patients have been ear- 
 lier hurried to a hectic state. 
 
 * Benjamin Bell's System of Surgcrj', seventh edit, vol, I, 
 
( 102 ) 
 
 Sea bathing, or the application of sea 
 water, as local remedies in these cases, have 
 not appeared to me to be attended with 
 success. But the sea air is manifestly use- 
 ful in improving the patient's health, and 
 by that means supporting him under the 
 excessive drain of a long-continued ulce- 
 rated joint; and in this respect I consider it 
 as a very important means of relief. 
 
 I have seen cases of diseased joints 
 evidently become worse after a residence 
 of several weeks at a sea-bathing place, al- 
 though the patient's health has considerably 
 improved. If the cases T allude to were in- 
 tended to ascertain the full effect, without 
 any other surgical assistance, of sea air and 
 bathing, the object was certainly obtained. 
 Several patients have applied to me on their 
 return home, and I was satisfied that relax- 
 ed and debilitated habits were certainly be- 
 nefited, but the local disease had evidently 
 increased ; whereas, in those who possessed 
 strength and health the consequences were 
 such as to hasten the progress of the affec- 
 
( 103 ) 
 
 tion of the joint to the suppurative stage of 
 the complaint. 
 
 I speak from observation, and not as a 
 theorist ; and it is hoped, that medical men, 
 who are resident on the sea-coast v^ill not 
 confide in the means, which their situation 
 provides as a remedy for white-swelling, but 
 employ also that treatment which is known 
 to be successful under circumstances in 
 which the patient cannot have the advan- 
 tages of sea air and bathing. 
 
 It will be obvious that, in the cases to 
 which I have more particularly alluded, 
 the antiphlogistic treatment should have 
 been employed; and it is reasonable to be- 
 lieve, that had the patient been so treated, 
 an abscess, which afterwards burst, might 
 have been prevented from forming. The 
 reader is referred to a most useful and excel- 
 lent written book on scrofula, therein he 
 will find Dr. Hamilton, the author, treat 
 this part of the subject with much practical 
 knowledge and great candour. I confess 
 my expectation of sea air and bathing has 
 
( 104 ) 
 
 been considerably lessened from having 
 found so many scroufulously diseased per- 
 sons natives of sea-bathing tow^ns. For 
 those who are not in possession of Dr. Ha- 
 milton's Treatise, I have extracted the fol- 
 lowing remarks : 
 
 '' I must confess that I have my doubts 
 " as to the sea waters possessing powers in 
 " a superior degree to any other medicine 
 " in the scrofula; nor do I think that it 
 *' merits the virtues given it by Russel 
 " and Speed. My reasons are the follow- 
 " ing, however heterodox they may ap- 
 " pear, but truth is my guide. 
 
 " I have long lived in a sea port town of 
 ^' great trade, and the haven from the town 
 ** to the opposite side is at least half a mile 
 '* wide. The distance from the town to 
 " the mouth of the river Ouze (which forms 
 " the haven) where it opens into Lynn 
 " Deeps, an extensive inlet from the Ger- 
 " man Ocean, is about two miles and a 
 " half. A large body of sea water flows 
 
( 105 ) 
 
 " from this inlet up the haven, many miles 
 *' above the town, twice in twenty-four 
 *' hours; and with the tide, we may sup- 
 *' pose, a very large share of sea air : and 
 " during the summer months sea bathing 
 *' is constantly used, when the time of high 
 ** water will admit of it, by men of all de- 
 " descriptions, and many of the boys are 
 *' seldom out of the water in the day time, 
 *' except at school hours, all summer ; yet, 
 *' it is no less strange than true, there are 
 " no where more distressed victims to the 
 " scrofula to be met with than at Lynn ; 
 *' and they are as frequently to be met 
 *' with amongst the lower orders of the in- 
 " habitants, who are used to the water 
 " daily, as in other ranks of life whose bu- 
 " siness has no connexion with it. And in 
 " no inland town within my knowledge, 
 " which extends at least thirty miles around 
 *' Lynn, did I ever see so bad cases of this 
 *' disease as in this town, in a course of 
 " more than forty years practice. 
 
 " The inference to be drawn from these 
 
( 106 ) 
 
 " remarks is, that if sea water and sea air 
 
 *' were such specifics, surely the scrofula 
 
 *' would be far less formidable at Lynn than 
 
 " in any of the inland towns, but it is a 
 
 *' melancholy truth that it is not so; and, 
 
 " from long observation, 1 am rather in- 
 
 " clined to think that it is really more se- 
 
 " vere and distressing. 
 
 " It may be alledged, that as moisture 
 will increase the laxity of the fibres it 
 will augment the symptoms of the dis- 
 ease in some scrofulous habits, conse- 
 quently this may be the cause why so 
 many have it so severely in this place. 
 Lynn certainly stands very low, so does 
 every town in a fenny situation in this 
 neighbourhood. Lynn is surrounded by 
 marshy grounds, and therefore there must 
 be a large evaporation from these as well 
 as from the large body of water in the 
 haven. The tow^ns in the fens, situated 
 from S. W. to N. W. of the town of 
 Lynn, are surrounded by large bodies of 
 fresh water, by the low fenny grounds 
 
( 107 ) 
 
 " being overflowed in the winter, and the 
 " evaporation from thence is prodigious; 
 *' and being fresh water, and hable to cor- 
 " ruption from putrid, animal, and vege- 
 " table matters, in this stagnant state, may 
 " be supposed to be more liable to increase 
 " the severity of this disease on that ac- 
 " count. But it does not appear to be so 
 *' in fact, at least I have not seen any 
 " number of instances in proof of this; 
 *' and Lynn possesses an advantage which 
 " the fenny situations do not; in them the 
 " evaporation becomes always stagnant^ 
 *' unless in high winds; but at Lynn vapor 
 " cannot be stagnant, but must be put in 
 " motion by the constant flux and reflux 
 " of the tides ; and it is well known, that 
 " when the remittent fever becomes epi- 
 " demic in this county, that it always rages 
 '* some weeks in the fenny situations of 
 " the above descriptions before it appears 
 " at Lynn, which we may presume is ow- 
 " ing to the salutary effects of the tides in 
 " not only causing a sort of ventilation 
 " through the eflluvia, and dispersing part 
 
( 108 ) 
 
 " of them into the upper regions of the 
 ** atmosphere, but also in washing into 
 " the same some of those putrid matters 
 '* which are partly the source of those in- 
 " fectious effluvia." 
 
( 109 ) 
 
 SECTION VIII. 
 
 ON THE EFFICACY OF ARTIFICIAL DRAINS. 
 
 X HE earliest records of surgery afford 
 abundant proof of the beneficial conse- 
 quences resulting from the use of the cau- 
 tery, moxa, raw flax, and escharotic appli- 
 cations. The reasonings and arguments the 
 earliest writers used* to explain the salu- 
 tary action of these remedies may appear 
 a little unphilosophical ; nevertheless they 
 
 noticed the very important effect of the 
 power they possessed, in the relief of dis- 
 eased joints, and in discussing fluids con- 
 tained within their cavity. Fienus's workf 
 may certainly be referred to, on account of 
 the mention he makes of the efficacy of 
 
 * fi'ijAXivov linum crudum. Vide ^Economia Hippocratis 
 sub voce, 
 .f Fiemis de cauteyiis, I59S. 
 
( no ) 
 
 cautery and caustic in other diseases, with 
 some interest and advantage. 
 
 Although he uses the latin word absor- 
 betur, yet it can only be considered as sy- 
 nonymous, with exsiccatur and consumi- 
 tur, but it is clear that they were as com- 
 pletely in possession of the advantages, to 
 be derived from the application of those re- 
 medies, as if they had been ever so well ac- 
 quainted with the absorbent system. This 
 author has well remarked that rubefacients 
 have a power to discuss fluids, but in a less 
 degree than the cautery, and he mentions 
 the latter remedy as superior to caustics in 
 this effect. I cannot take my leave of this 
 author without quoting a practical caution 
 I think worthy of communication in his 
 own words, " semper periculosus est caute- 
 riorum in calidis afFectionibqs usus." 
 
 The great success generally attending the 
 use of caustics in curvatures of the spine, 
 arising from a diseased state of the bodies 
 of the vertabrae, induced me to extend the 
 remedy to white-swellings of the joints of 
 
( 111 ) 
 
 the limbs. Sir James Earle* acquaints us 
 that " Mr. Pott used caustics in scrophu- 
 *' lous swelUngs of the knee, where there 
 " was suspicion of beginning caries; they 
 " were applied just above and below the 
 " joint ; in some cases they seemed to be 
 " materially serviceable, in preventing the 
 " increase of the swelling, but in many 
 ** others they failed. In similar diseases 
 *' of the joint of the ancle, he also tried 
 " them, but according to the observation 
 " of a very ingenious and accurate observerf 
 " the effect of the caustics seems to be in- 
 " versely as the distance of the part af- 
 " fected from the trunk ; in these joints no 
 " advantage appeared to be derived from 
 *' them." On reading the above note, I 
 confess at the time to have regarded Dr. 
 Austin's observation as one which might 
 be anticij)ated as coming rather from a pro- 
 fessed theorist, than a practical surgeon, so 
 dissatisfied was I, at the Doctor's conclu- 
 sion, that I embraced the earliest opportu- 
 nity of applying caustic issues on each side 
 
 *' Earle's edition of Pott"» Works, vol. Ill, 
 ' t ^^' Austin. 
 
( "2 ) 
 
 of a joint. In the year 1793 I published 
 three cases, considerably benefited, but not 
 cured by the application of the caustic. 
 These and many other proofs since of their 
 efficacy have fully confirmed the opinion 
 I then formed, when I said that the 
 failure has been supposed to be owing 
 to the greater distance of the limb from the 
 heart ; it may be rather apprehended that 
 in the extremities the application was not 
 made near enough to the seat of disease. 
 
 Whether the practitioner apply caustics 
 or blisters, dressing the blistered surface, 
 after the cuticle is removed, with the savine 
 cerate, yet local bleeding should always pre- 
 viously be had recourse to. It is now my 
 practice to blister the sides of the joint, leav- 
 ing the interspace for the occasional applica- 
 tion of leeches which I very generally find 
 necessary during the cure. This mode of 
 treatment is preferable, as it is equally effi- 
 cacious and less irritating than when I blis- 
 tered the anterior and lateral surfaces of the 
 joint, for I have by this means experienced 
 less irritation and spasmodic affection. 
 
( "3 ) 
 
 I have often been obliged, by the occur- 
 rence of recent inflammation during the 
 treatment by the savine cerate, an inconve- 
 nience to which the remedy by the caustic 
 has also been occasionally subject, to apply 
 leeches to the sore surface. They will, I 
 have found, take hold, and considerably 
 more blood will be abstracted than will fol- 
 low their application to a sound skin. A 
 patient of mine, an acquaintance of Mr. Hey 
 the surgeon, was relieved of violent suf- 
 fering from inflammatory attacks, which 
 occasionally occurred during a long atten- 
 dance, in a case of a very bad diseased knee, 
 and so far advanced was the complaint in 
 this instance, that Dr. Marshall intimated 
 his fearsj that the gentleman's case might 
 be irrecoverable, and I should gain no credit 
 by my attendance. This patient however 
 got completely well, and has since frequent- 
 ly rode a journey of fifty miles on horse- 
 back at one time. 
 
 After the disease is cured, it is often a 
 length of time before the patient regains 
 the natural strength and use of the joint.. 
 
 I 
 
( 114 ) 
 
 I determined that my treatment should 
 recommend itself on the ground of its 
 own merit, unaided by the good opinion 
 or recommendation of any of my medical 
 friends. 
 
 The present publication affords me an 
 opportunity of returning Dr. Marshall my 
 best acknowledgements for the countenance, 
 and encouragement I experienced from him 
 in the several cases, which I submitted to 
 his excellent judgment. 
 
 Of the customary remedies applied in 
 cases of white- swelUngs, blisters have had 
 the preference ; and their efficacy has by 
 some been supposed to arise from the sti- 
 mulus, more than from the discharge they 
 produce. Practitioners of this opinion have 
 blistered the whole joint, and suffered the 
 part to heal before another blister was ap- 
 plied ; and in this way, they have kept up a 
 constant succession of stimuli. 
 
 Others being of opinion that the discharge 
 and not the stimulus produced advantage, 
 
( 115 ) 
 
 have had recourse to perpetual blisters; and 
 though I never saw any permanent good 
 arise from the first mentioned mode of em- 
 ploying these remedies, yet, in a case of 
 diseased hip, a large perpetual blister placed 
 behind the trochanter, was attended with 
 remarkable success. 
 
 Dr. Akenside published a paper in the Me- 
 dical Transactions, on the efficacy of blisters 
 in cases of white-swelling, in which altera- 
 tive medicines, as calomel and bark, were 
 given. He states, that he had been able by 
 these means to restore the use of one or other 
 of the principal joints, where the case seemed 
 very near to an anchylosis ; but the Doctor 
 remarks, that nothing can be expected from 
 this treatment, where there is any sensible 
 collection of fluid within the joint. He 
 seems, in the first instance, to have applied 
 a blister round the whole joint, and after- 
 wards to have kept up a discharge from a 
 circumscribed spot over the painful part; 
 he also lays some stress upon the use of oily 
 frictions, where the motion of the limb was 
 impaired. 
 
 I 2 
 
( 116 ) 
 
 His cases, however, were not all scrofu- 
 lous : I think two of them were so, and in 
 these the discharge was kept up for a con- 
 siderable length of time. 
 
 From the irritation and the strangury oc- 
 casioned by perpetual blisters, I was first led 
 to apply caustics ; the comparative advan- 
 tages of these two remedies depend in some 
 degree upon circumstances unconnected 
 with partiality in favor of one or the other 
 application. If the integuments are in- 
 flamed, or have become thin, and if fluid 
 be collected beneath them, the use of caus- 
 tics cannot be adopted with safety. 
 
 A surgeon was induced to apply the caus^ 
 tic, in a case of a diseased knee, on each 
 side of the joint, where the integuments 
 were thickest ; and the eschar was so si^ 
 tuated, that its centre covered the spacQ 
 where the femur is applied to the tibia. 
 This situation was attended with danger j 
 for as soon as the eschar, covering the inner 
 condyle, had separated, an opening, hardly 
 capable of admitting the end of the probe, 
 
( 117 ) 
 
 was found to communicate with the joint, 
 from which the synovia was discharged; 
 and this appearance first led to a discovery 
 of the accident. This patient certainly died 
 earUer in consequence of this unfortunate 
 circumstance, although he would soon have 
 been destroyed by the diseased state of his 
 lungs, which contained a great number of 
 scrofulous tubercles, many of which had sup- 
 purated, as appeared upon opening the chest. 
 
 I became also acquainted with another 
 instance in which the caustic penetrated an 
 «lbow joint, and the patient was obliged to 
 45ubmit to amputation. The calamities, 
 which befel these patients, must surely have 
 excited very painful sensations within the 
 breasts of those practitioners who attended 
 the cases, and it is hoped that their misfor- 
 tune will operate as a caution to others, and 
 induce them to form the eschar above the 
 condyles of the femur or humerus, which 
 situation will obviate all possibility of in- 
 cluding the capsular ligament within the 
 operation of the caustic. 
 
(118 ) 
 
 The kali purum was the application used 
 on the occasion just alluded to, but had the 
 calx cum kali puro been employed, I am in- 
 clined to think this accident would not have 
 happened : for, certainly, independent of the 
 kali purum being a very powerful caustic, 
 its operation must be accelerated by the 
 friction employed in its use. 
 
 Should a preference be given to a caustic 
 issue, it may be kept open by means of the 
 sponge tent. I would by no means re- 
 commend the caustic for the purpose of 
 maintaining an artificial drain in any case, 
 in which the integuments are thin, and will 
 not allow of being elevated by the fingers. 
 The capability of their being collected 
 into folds, will be the surest test that the 
 application may be employed without the 
 hazard, which would attend its use, should 
 the integuments be closely adherent to the 
 cellular membrane in consequence of pre- 
 vious inflammation. 
 
 The Editor of the Pharmacopoeia Chi- 
 rurgica, speaking of the caution necessary 
 
( 119 ) 
 
 to confine this application within due limits, 
 says, that on account of the disposition of 
 the kali purum to act laterally " it should 
 " rather be twirled between the fingers 
 " and thumb, than employed with a cir- 
 *' cuitous motion of the hand." I can 
 practically say, that, if the moisture is ab- 
 sorbed by a dossil of lint as the eschar is 
 making, the space destroyed by the caustic 
 ^11 correspond to the boundary first de- 
 signed, as truly as if the paste caustic had 
 been applied to the part, and encircled by 
 an elevated margin of adhesive plaister. 
 
 Instances have occurred in my practice, 
 in which the irritation of blistering a joint, 
 and dressing the part with the savine cerate, 
 was so insufferable, that I have been obliged 
 to have resource to caustic. A very dis- 
 tressing case of this kind occurred, in w^hich 
 the savine cerate excited such considerable 
 inflammation within the joint, as to induce 
 the patient to submit to amputation : I was 
 not present at the time the circumstance 
 occurred, or certainly should have recom- 
 mended the antiphlogistic treatment; and 
 
( 120 ) 
 
 have little doubt, from experience, that the 
 irritation would have been removed. 
 
 When I first applied caustics for the re- 
 lief of diseased joints, the sores were kept 
 open bj an occasional dressing of the un- 
 guentum cantharidis, or by an escharotic 
 application ; but, before it could be known 
 what effect the caustic issue would produce, 
 1 found that the blister ointment, as well as 
 the escharotic applications, gave more pain 
 than the patient could well bear. To pro- 
 mote a discharge from the sores in an easier 
 way, I made use of a layer of sponge, dipt 
 in melted wax, and pressed flat, which was 
 cut nearly to the size of the sore, to which 
 it was confined by cross slips of adhesive 
 plaister. The same intention may be an- 
 swered by pouring melted wax on two or 
 three layers of lint laid on each other, but 
 whether the lint or the sponge be used, the 
 wax appUcation should be less than the 
 sores, so as to allow room sufficient for the 
 granulations at their edges to rise above 
 its surface; thus will the waxed lint or 
 sponge be confined in its situation, the use 
 
( 121 ) 
 
 of the blister ointment be rendered unne- 
 cessary, and the bandage required to keep 
 on the dressings will prevent any fungus 
 that can be distressing to the patient or trou- 
 blesome to the surgeon. Should the sores 
 contract they may be enlarged to the extent 
 wished for, by applying sponge that has been 
 dipped in the melted emplastrum cerae com- 
 positum ; sponge thus prepared will swell 
 out, which is not the case when it is filled 
 merely with wax: the plaistered applica- 
 tion has frequently enabled me to shift the 
 sore a little higher or lower on the one side 
 or the other, by pressing the sponge in the 
 direction to which I wished the issue to 
 extend. 
 
 If from any circumstance the granulating 
 border should be destroyed, it can be re- 
 newed by applying a sponge tent of rather 
 smaller circumference. 
 
 Whoever has used both remedies will, I 
 think, agree with me, that the curative ope- 
 ration of the caustic is slower and weaker ; 
 and that it must therefore be considered as 
 
( 122 ) 
 
 inferior to the application of blisters com- 
 bined with the savine dressing. The issues 
 may be sufficiently efficacious in those af- 
 fections of the joints, which consist rather 
 in a general thickening of parts, than in 
 any actual effusion within the articulation ;. 
 and they may deserve a preference in such 
 cases from being less irritating : yet I will 
 affirm without hesitation, as the result of 
 my general experience, that blisters and the 
 savine cerate are decidedly pre-eminent in 
 promoting the absorption of fluid extrava- 
 sated within the cavity of a joint. 
 
 I select the following narrative out of 
 many facts which I could adduce in proof 
 of the beneficial effects of this treatment in 
 eases of hydarthrus, 
 
 A gentleman applied to me for a disease 
 of the knee-joint, in which I observed the 
 following particulars : the patella was con- 
 siderably elevated, and produced, on mo- 
 tion, a grating sensation. A considerable 
 quantity of fluid was collected in the cap- 
 sule; great uneas'mess was experienced on 
 
( 123 ) 
 
 the least exertion, and the integuments ap- 
 peared in a puffy state. Twelve ounces of 
 blood were removed from the part by cup- 
 ping, and the aqua ammoniae acetata was 
 constantly employed as a lotion. These 
 remedies occasioned a considerable dimi- 
 nution of the swelling of the integuments, 
 and a very palpable decrease of the extra- 
 vasated fluid. A blister was afterwards ap- 
 plied on the inside of the knee, and the 
 blistered surface was dressed in the usual 
 manner. Within three months the patient 
 recovered, and on moving the knee a gra- 
 ting noise was no longer heard. I wish 
 the student, in examining a case of hydar- 
 thus, would pay particular attention to the 
 feel, which is conveyed on handling the 
 puffy integuments, and that which is pro- 
 duced by pressing the fluid from one side 
 of the articulation to the other: he will 
 perceive an impetus in the one instance 
 which is wanting in the other ; this will 
 enable him to ascertain more infallibly whe- 
 ther the tumefaction of the external parts 
 arise from sympathetic affection, or from 
 the accumulation of fluid within the joint. 
 
( 124 ) 
 
 It is now more than fourteen years since 
 I first recommended the application of caus- 
 tic on the integuments covering a diseased 
 joint, from an opinion that issues would 
 prove more effectual, the nearer they were 
 made to the seat of the disease. I then 
 stated, that this opinion had something 
 more than probable conjecture to recom- 
 mend it ; and indeed subsequent experience 
 has fully confirmed me in the belief, that 
 the failure of the caustic in these cases was 
 not owing, according to the opinion of 
 Dr. Austin, to the distance of the part 
 affected from the trunk, but to the circum- 
 stance of the discharge not being procured 
 from the immediate neighbourhood of the 
 complaint : the reader will of course form 
 his own opinion from the comparative suc- 
 cess attending the more distant or closer 
 application of the remedy, from the evi- 
 dence hereafter to be detailed. 
 
 Notwithstanding the success which at- 
 tended the application of the caustic, the 
 very minute attention it requires made me 
 apprehensive, that it would never be gene- 
 
( 125 ) 
 
 rally adopted. I was of course led to the 
 trial of different escharotic applications, in 
 the form of ointment, and amongst others, 
 I was induced, from observing the elfFects 
 of powdered savine, in the removal of 
 w^arts, to give it a trial. Some of the 
 powder was first mixed with white cerate, 
 and applied as a dressing to the part that 
 had been blistered ; but the ointment ran 
 off, leaving the powder dry upon the sore, 
 and no effect was produced. I next in- 
 spissated a decoction of savine, and mixed 
 the extract with the ointment, which suc- 
 ceeded better, for it produced a great and 
 permanent discharge. At last, after va- 
 rious trials, I was led to prefer a prepara- 
 tion analogous to the unguentum sambuci, 
 P. L. and I now offer the following for- 
 mula, as answering every purpose which 
 my wishes could have suggested : — 
 
 R Sabinae recentis contusae libras duas. 
 Cerae flavse libram 
 Adipis suillae libras quatuor. 
 Adipe et cera liquefactis incoque sabinam et cola. 
 
 The difference of this formula from the 
 one I published in 1797^ cpnsists only ih 
 
( 126 ) 
 
 using a double proportion of the savinc 
 leaves. The ceratum sabinae of Apothe- 
 cary's Hall is admirably made: they bruise 
 the fresh savine with half the quantity of 
 lard, which is submitted to the force of an 
 iron press, and the whole is added to the 
 remainder of the lard, which is boiled until 
 the herb begins to crisp, the ointment is 
 then strained off, and the proportion of wax 
 ordered, being previously melted, is added 
 to the composition. 
 
 On the use of the savine cerate, imme- 
 diately after the cuticle raised by the blister 
 is removed, it should be observed, that ex- 
 perience has proved the advantage of using 
 the application lowered by a half or two- 
 thirds of the unguentum cerse : an attention 
 to this direction will produce less irritation 
 and more discharge, than if the savine ce- 
 rate is used in its full strength. I have 
 also found that fomenting the part with 
 flannel wrung out of warm water, is a 
 more easy, and therefore a much preferable 
 way of keeping the sore clean, and fit for the 
 impression of the ointment, than scraping 
 
( 127 ) 
 
 the surface, as has been directed by others. 
 An occasional dressing of the unguentum 
 resinae flavae has been found by me to be a 
 very useful application in rendering the sore 
 free from an appearance of slough, or what 
 I ought rather to term dense coagulable 
 lymph, which in some cases has proved of 
 so firm a texture as to be separated by the 
 probe with as much readiness as the cuticle 
 is detached after blistering. It is hardly 
 necessary to direct that, as the discharge di- 
 minishes, the strength of the savine dressing 
 should be proportionally increased. 
 
 The ceratum sabinae must be used in a 
 stronger or weaker degree, proportionably 
 to the excitement which it produces on the 
 patient's skin. Some require a greater sti- 
 mulus than others, for the promotion of 
 discharge, and this can only be managed* 
 by the sensations which the irritation of 
 the cerate occasions. This application was 
 in public use three years before I wrote 
 upon its efficacy — chance introduced it — 
 publicity has given it credit, and, as a re- 
 
( 128 ) 
 
 medy of the suppurative kind, it continues 
 unrivalled. 
 
 I have used ointments impregnated with 
 the flowers of the clematis ereta, with the 
 capsicum, and with the leaves of the digi- 
 talis purpurea: the two first produced no 
 effect, the last was very stimulating, and 
 I shall employ the first convenient opportu- 
 nity to determine its qualities more accu- 
 rately. 
 
 I have also used kali purum rubbed down 
 with spermaceti cerate, in the proportion of 
 one drachm to an ounce : it proved very sti- 
 mulating but produced no discharge. In 
 one instance I used an application after blis- 
 tering, consisting of one drachm of hydrar- 
 gyrus muriatus to two ounces of the above 
 cerate. It was so intolerably painful, that 
 I was sent for at the end of about two 
 hours, and found it necessary to remove the 
 dressing immediately. The patient was at- 
 tacked with the most severe ptyalism I ever 
 witnessed. 
 
( 129 ) 
 
 CASE L 
 
 1 was desired to visit a man, about twen- 
 tj-seven years of age, who had laboured 
 under a white-swelling of the knee for 
 more than twelve months. He suffered 
 great pain within the articulation, before 
 the joint appeared to enlarge, and his case 
 was treated as a rheumatism. However, 
 instead of receiving benefit, he gradually 
 grew worse, and was admitted into a hos- 
 pital, where he was first salivated, with not 
 the smallest advantage. A blister was then 
 applied to the joint, and repeated every 
 other day, for the space of a fortnight. He 
 stated, that this method procured him con- 
 siderable ease, with some reduction of the 
 swelling. When I saw him, he was in a 
 confirmed state of hectic; had been troubled 
 with rigours ; the joint was much enlarged 
 and very painful, particularly in one part, 
 where the skin was thin and inflamed. 
 Indeed, both from the appearances and by 
 examination, I was fully satisfied that mat' 
 
 K 
 
( 130 ) 
 
 ter had formed. I advised him, on ac- 
 count of the state of his health, to part 
 with the Umb ; but he dechned the opera- 
 tion, telling me he quitted the hospital, as 
 nothing farther was proposed. 
 
 I made a large eschar on each side of the 
 joint, by rubbing the hali piirum on the 
 part, and the sores were kept discharging, 
 by means of prepared sponge. 
 
 In this case, no ease was derived from the 
 stimulus of the caustic ; but after the sores 
 had discharged freely for some time, his 
 pains were mitigated, and his health im- 
 proved. 
 
 The previous painful state of the part, 
 prevented, before a minute examination, 
 which would have ascertained that the ends 
 of the bones were deprived of their cartila- 
 ginous covering, by the grating noise that 
 was occasioned upon moving the joint. 
 By the continuance of this drain, for nearly 
 eighteen months, his knee got perfectly 
 
( 131 ) ^ 
 
 well ; its motion was unimpaired, nor waS 
 the grating sound any longer perceivable 
 upon using the joint. 
 
 This man had also a similar affection of 
 his ankle joint, attended with ulcerations 
 and extensive caries, on which account he 
 submitted to amputation; and though the 
 knee had remained well a twelvemonth, 
 and was so at the time of the operation, 
 yet it was considered right to amputate 
 above it. I very much regret I had not 
 the opportunity of examining the diseased 
 parts. 
 
 CASE 11. 
 
 S. G. a child, about the age of seven, had 
 an indolent white-swelling, for upwards of 
 two years; the whole joint was greatly 
 swelled, and the inner condyle of the thigh- 
 bone appeared enlarged. 
 
 She appeared to be ver\^ consumptive, 
 and breathed with difficulty ; her skin was 
 
 K2 
 
( 132 ) 
 
 yellow, drj, hot, and scurfy ; and she made 
 little, and sometimes no water in the course 
 of the day ; her belly was also swollen, and 
 the glands of the neck enlarged. In con- 
 sequence of the weak state the child was 
 in, a sore was made by the caustic, on the 
 inside of the joint, that part being most 
 diseased, and was only kept open by the 
 prepared sponge. When it had discharged 
 only a few weeks, her skin became cool 
 and perspirable ; her appetite was im- 
 proved, and her breathing relieved ; she 
 became easy, and her sleep was uninter- 
 rupted by those spasms of the affected 
 limb, with which she had been before 
 troubled. 
 
 In every respect she was mending, until, 
 unfortunately, she caught cold, by sitting 
 at the window, to view the flames from 
 the fire at Radcliffe, which imprudence 
 produced a fever, and a large deep-seated 
 abscess formed on the outside of the knee. 
 I ascertained that the fever was not symp- 
 tomatic of the abscess, but that the abscess 
 depended on the fever, from the mother's 
 
account, who informed me, that trie cunu. 
 had for two days been very feverish, before 
 any alteration in the j oint took place, or she 
 had complained of any pain. It was pretty 
 certain, that if the abscess had burst, or 
 been opened, the child would have been 
 drained to death ; but the joint having been 
 considerably reduced in size, by the first 
 application of the caustic, I was tempted to 
 apply it again, on that part of the skin 
 which immediately covered the abscess, 
 taking the greatest care that it did not pe- 
 netrate into the tumour. After the eschar 
 had separated, and the sore had discharged 
 freely, the child became easier, and the ab- 
 scess gradually dispersed. The issues were 
 kept open, first by the sponge, and after- 
 wards by the savine cerate, for upwards of 
 two years, at the end of which time she 
 was in every respect healthy, and the joint 
 appeared free from any disease, though there 
 remained a slight enlargement of the inner 
 condyle ; however,' probably she will be 
 obliged to wear a lift to her shoe, in conse- 
 quence of the contracted state of the knee. 
 
( 134 
 
 CASE III. 
 
 S. R. a scrofulous child, about seven 
 years of age, was brought to me, on account 
 of an indolent white-swelling affecting the 
 knee, which had been diseased above two 
 years; the whole joint was much tumefied, 
 and a fluctuation was to be felt in its ante- 
 rior and lateral parts. Although the child 
 did not feel much pain when the part was 
 handled, yet she expressed great uneasiness, 
 when the joint was moved. The integu- 
 ments covering the part appeared puffy and 
 thickened, though not in the least oedema- 
 tous, and the colour of the skin was re- 
 markably pallid. A sore on each side of the 
 joint was made by the caustic, and kept 
 open, by the prepared sponge, for about six 
 months. This child, when I first saw her, 
 was certainly consumptive, but her health 
 gradually amended, and is now perfectly 
 good, and her joint free from any disease. 
 I saw her lately (upwards of two years after 
 lier issues were healed) and she appeared 
 
( 135 ) 
 
 completely well. I examined the knee, and 
 it measured about half an inch more than 
 the other, which is probably owing to an 
 enlargement of the inner condyle of the 
 thigh bone, and not to any affection of the 
 soft parts covering the articulation. 
 
 CASE lY. 
 
 I. G. aged nine years, of a scrofulous 
 habit (as were also his parents) had laboured 
 under a white- swelling of the knee for 
 above two years. Before half of that time 
 had elapsed, an abscess formed above the 
 joint; for a short time, he seemed relieved, 
 his knee being less painful, and the com- 
 plaint at a stand. 
 
 He applied to me, in a state of hectic; his 
 knee measured twice the size of the other, 
 he felt great pain in the ends of the bones, 
 and within the articulation, and there was 
 a very considerable quantity of fluid to be 
 felt over the whole joint. His parents not 
 consenting to an amputation, the caustics 
 
( 136 ) 
 
 were applied on each condyle, and the sores 
 maintained open by the sponge. A copious 
 discharge being kept up for the space of a 
 few weeks, effected a considerable amend- 
 ment in his health, and some improvement 
 took place also as to the joint, for he could 
 bear it to be handled and moved with less 
 pain, and the swelling was abated. He 
 continued getting better, and recovered so 
 wxll, as to be able to walk every day, for 
 six months, to my house, which is a full 
 mile from the place of his abode ; during 
 which time, his health was remarkably 
 good, and the joint appeared free from dis- 
 ease^ excepting a degree of enlargement in 
 the bone, which, however, was no impe^ 
 diment to its action. 
 
 As he was one day returning to his father's 
 house, he felt suddenly a great pain within 
 the joint, which obliged him to be carried 
 home, and in a few weeks he died hectic, 
 in consequence of the inflammation and 
 suppuration which ensued. 
 
 A particular examination of the joint wasr 
 
( 137 ) 
 
 not allowed; but an incision into it, dis- 
 covered the ends of the bones eroded and 
 enlarged ; and I found, by introducing my 
 finger into an opening, caused by the dis- 
 ease, in the thigh bone, that its cellular 
 structure was destroyed, the ligaments were 
 greatly diseased, and the capsular ligament 
 was also perforated in one part. 
 
 CASE Y. 
 
 I. T. a young woman, twenty years of 
 age, was admitted into St. Clement's Work- 
 house, on account of an indolent white- 
 swelling, she had been afflicted with, for 
 above a year and a half. The joint was 
 very puffy, and the skin pallid, though not 
 oedematous, she felt great uneasiness within 
 the articulation, and, when the joint was 
 moved, the bones were perceived to grate. 
 She had been in a Hospital, where the part 
 had been frequently cupped, with the ad- 
 vantage only of mitigating her pain. 
 
 Besides the complaint of her knee, she 
 
( 138 ) 
 
 had a violent pain in her side, profuse cold 
 sweats, with alternate heats, and an entire 
 loss of appetite and sleep. She felt most 
 of her pain within the joint, between the 
 bones, and under the knee-pan, through 
 to the ham. This patient, for about six 
 months, submitted to the same kind of 
 treatment as was used in the preceding 
 case, to which she owes a complete reco- 
 very of her health and joint. I have seen 
 her very lately, she walks well, and there 
 is not the least grating to be perceived, or 
 indeed any apparent disease about the joint. 
 
 CASE YI. 
 
 A little girl had a scrofulous elbow, 
 which had ulcerated, and the bones were 
 heard to grate, she besides laboured under 
 strumous ophthalmy, and swellings of the 
 glands of her neck. The caustics were ap- 
 plied on each side of the joint, taking care 
 to make the eschars sufficiently remote from 
 the sores, which the disease had made. 
 After the issues had been kept open for 
 
( 139 ) 
 
 upwards of six months, bj the sponge, her 
 health was completely restored, the ulcers 
 healed, the complaint in her neck and eyes 
 were removed, and the disease of the elbow 
 was cured, though the case terminated in 
 ossific anchylosis ; but as the arm was kept 
 bent during the cure, she had a very useful 
 limb. 
 
 CASE YII. 
 
 S. M. D. a boy, about five years of age^ 
 had a white-swelling of his knee, of some 
 date ; and notwithstanding the interposi- 
 tion of the fluid of the joint, the end of the 
 thigh-bone was perceptibly enlarged ; the 
 usual applications had been made, but to no 
 effect, as several abscesses formed about 
 the joint, but no exfoliation had occurred ; 
 and when the boy was brought to me, his 
 health had suffered much by repeated ul- 
 cerations. I applied the caustic on each 
 side of the joint, so as not to interfere with 
 the sores the complaint had caused; and 
 
( 140 ) 
 
 this artificial discharge was maintained for 
 a year and a half. 
 
 The result of this treatment was a per- 
 manent healing of the ulcers, which existed 
 previous to the application of the caustic, 
 attended with a reduction of the joint to 
 its natural size, and a perfect recovery of 
 its motion,* 
 
 CASE VIII. 
 
 T. B. about six years old, had been af- 
 flicted with a white-swelling of his elbow, 
 above eight months, and it then was ulce- 
 rated in seven places ; he had also a stru- 
 mous affection of his great toe on the left 
 foot, a scrofulous abscess and two sores on 
 
 * Of a case, the particulars of which have been mislaid, I 
 can only state, that the caustics, after a drain had been kept up 
 for above a year, succeeded in curing a diseased knee of some 
 standing, in which there was great swelling of the soft parts, 
 with enlargement of bone, which enlargement, however, re- 
 mained, after all pain and tamefaction of the integuments 
 tod subsided. 
 
( 141 ) 
 
 the right leg, besides a strumous opthalmy 
 which had subsisted from the fourth year 
 of his age. On account of the inflamed 
 state of the elbow, six leeches were applied^ 
 and cloths wrung out of the saturnine lotion, 
 were kept to the part, and renewed when 
 dry. Though this treatment in a degree 
 relieved the inflammation, yet the sores 
 did not indicate the smallest disposition to 
 heal. A large caustic was applied above 
 the elbow-joint, the ulcers preventing its 
 nearer application ; the issue was kept 
 open for about ten months, when the 
 ulcers, formed by the disease, had com- 
 pletely healed, and the joint recovered. 
 
 This case aifords a very striking instance 
 of the constitutional effect of artificial drains ; 
 as under this treatment, he entirely got the 
 better of all the complaints which have 
 been enumerated. On account of his dis- 
 position to scrofula, before the sore made 
 by the caustic was healed, I cut him an 
 issue in the arm. 
 
 I have almost daily opportunity of see- 
 
( 142 ) 
 
 ing this boy, as he lives in my neighbour- 
 hood, and he has not since had any com- 
 plaint, though a period of nearly three 
 years has elapsed. 
 
 CASE IX. 
 
 M. H. a girl, about five years of age, was 
 troubled v^ith a white- swelling of the right 
 elbow, which was attributed to her having 
 fallen from a swing. The mother discover- 
 ed the joint to be larger than the other, and 
 that she favoured it, and complained on its 
 being moved. The skin covering the dis- 
 eased part was pallid, and the integuments 
 were thickened, though no impression of 
 the finger remained after handling. This 
 child laboured under weak eyes, had a 
 swollen belly, the glands of her neck en- 
 larged, and she was drowsy and inactive. 
 Two sores were made by the caustic, on 
 each side of the joint, and were kept dis- 
 charging for about six months, when her 
 elbow got well, and her health recovered. 
 At the mother's solicitation, I healed the 
 
( 143 ) 
 
 sores, but in about two months, the swel- 
 hng of the elbow returned, and there was 
 a chain of lymphatic tumours extending 
 from thence, towards the axilla, and she 
 relapsed into her former ill state of health. 
 Some time after, I observed, that though 
 the articulation was considerably distended 
 with fluid, the integuments were unaffected. 
 
 The advantages derived from the first ap- 
 plication of the caustic, encouraged the pa- 
 rents to hope, that a second trial would 
 prove equally successful; but though the 
 child did perfectly recover from the disease 
 of the elbow, after the second drain had 
 been established, yet it required twice the 
 time in this instance, to complete the cure. 
 "Whether the diseased state of the lympha- 
 tics had any share in thus protracting the 
 cure, I shall leave the reader to determine 
 for himself. The swelling of her belly sub- 
 sided, as did the glands in her neck, except- 
 ing one, which was scarcely to be felt. 
 
 A common issue was made in her arm at 
 a time the discharge by the caustics was 
 
( 144 ) 
 
 suppressed ; her health has remained for 
 nearly three years remarkably good, and 
 her elbow, entirely free from disease, is 
 equally strong and useful as the other. 
 
 CASE X. 
 
 R. N. a scrofulous boy, eight years old, 
 had a diseased knee, for about four years, 
 which was much contracted, as he had been 
 suffered to keep the limb in a state of 
 flexion. The part was considerably en- 
 larged and painful, and from the boy's 
 general health, and the appearance of the 
 skin, I had no doubt, of its being matter 
 which fluctuated under my fingers. The 
 caustics were applied on each side of the 
 joint, avoiding a part which was thin and 
 inflamed, and the sores were kept open for 
 about ten months ; the boy's health gradu- 
 ally became good, the fluid collected in and 
 about the joint was entirely absorbed, and 
 the pain removed, though there remained 
 some enlargement of the inner condyle. I 
 wished to remove the limb, because the con- 
 
( 145 ) 
 
 traction of the knee rendered it of no use, 
 and it was only in his way; but the mother 
 objecting, I directed the issues to be kept 
 open ; this advice was not followed, and 
 though the knee preserves its improved 
 state, yet a scrofulous abscess has formed 
 in the middle of his leg. 
 
 CASE XL 
 
 A young lady felt a pain in her knee, 
 three years before I saw her, which was 
 exasperated by walking, long standing, or 
 any kind of fatigue ; the joint was con- 
 tracted, much enlarged, and the integu- 
 ments were in a thickened, puffy state, 
 and of a pallid appearance, though not 
 oedematous. She described her pain as 
 particularly severe in the inner condyle, 
 and under the ligaments of the knee-pan, 
 shooting from thence into the joint. The 
 part was at different times cupped or 
 leeched, and a large blister applied. As 
 the case occurred before my knowledge of 
 the effects of savine, I employed the ung. 
 
( 146 ) 
 
 eantharidis to keep up the discharge, which 
 produced great pain and strangury. I 
 therefore appHed the caustic on each side of 
 the joint, and kept the sores open by the 
 plaistered sponge. I wish particularly to 
 remark, that she always expressed herself 
 relieved in proportion to the quantity of 
 discharge. This patient continued under 
 my care for two years, and nearly the 
 whole of that time, a drain was main- 
 tained, either by the prepared sponge, or by 
 the savine cerate, a blister being previously 
 applied. Her knee is perfectly recovered, 
 she can straighten or bend the joint without 
 pain, and her health, which had suffered 
 very considerably, is now completely re- 
 established. I cannot suiHciently commend 
 the patience with which the lady, who is 
 the subject of the present case, has borne 
 her sufferings. ]ndeed, the circumstances 
 were particularly unfavourable ; for a very 
 near relation had fallen a victim to the same 
 disorder, and but for a visible improvement 
 in her general health, I should frequently 
 have proposed amputation of the limb, as 
 preferable to the mLsery she endured. To 
 
( 147 ) 
 
 secure her from a relapse, and as she had 
 been troubled with swellings of the glands 
 of her neck, I cut an issue above the knee. 
 
 CASE XIT. 
 
 R. D. of a scrofulous habit, had a diseased 
 knee, for above three months. He de- 
 scribed his pain, as first originating in the 
 inner condyle of the os Jemoris, under the 
 patella, and within the articulation, before 
 the part manifested any swelling. — The 
 customary applications had been previously 
 used, with no advantage; but as he had 
 lately contracted some venereal complaint, 
 it was thought adviseable, to try how far 
 mercury would relieve the diseased joint; 
 he was directed to rub mercurial ointment 
 on the affected limb every night, for about 
 six weeks, which salivated him, though it 
 did not in the smallest degree alleviate the 
 pains of the joint, which were not more 
 exasperated in the evening, than at any 
 other period of the day. He was afterwards 
 admitted into St. Clement's workhouse, 
 L 2 
 
( 148 ) 
 
 when his health was much impaired, from 
 the uneasiness of the joint, and loss of sleep 
 and appetite. An eschar was made, by the 
 application of the caustic, on each side of 
 the joint, which was pufFj, much enlarged, 
 and somewhat contracted ; and the sores 
 were kept open, bj the prepared sponge, for 
 about four months, after which period the 
 joint became perfectly free from disease, 
 though some further time was necessary 
 for it to acquire its usual strength. About 
 two years after, in consequence of his ap- 
 plication to me on account of another dis- 
 ease, I had an opportunity of examining the 
 joint ; he told me it was equally strong and 
 useful as the other, and I could not discoYcr 
 any vestige of disease. 
 
 CASE XIII. 
 
 I was desired to visit £. C. who had been 
 two years afflicted with a diseased knee, 
 and had suffered great pain in the condj'les 
 of the thigh-bone, under the knee-pan, and 
 within the articulation, for some time be- 
 
( 149 ) 
 
 fore there was any appearance of swelling. 
 The joint was in a contracted state, and of 
 twice its natural size ; the integuments ap- 
 peared puffy, and were thickened, but not 
 cedematous, and the colour of the skin was 
 remarkably pallid. As the joint was ra- 
 pidly becoming more and more painful, 
 and as her health was materially affected, a 
 removal of the limb was twice proposed, in 
 consultation, as the only means of relief. 
 The caustics in this case, were applied on 
 each side of the joint, not with any expec- 
 tation of cure, but rather as a palliative sort 
 of remedy, and to prevent the repetition of 
 abscesses, which always attend the latter 
 stage of white-swellings. 
 
 The sores were kept open by the sponge, 
 for about a year, in which time the joint 
 progressively recovered. This patient was 
 not relieved by the irritation the caustics 
 first produced ; for, indeed, after the sores 
 had' discharged freely for some weeks, the 
 improvement that took place in her health, 
 was the first circumstance which afforded 
 the smallest ray of hope. 
 
( 150 ) 
 
 CASE XIY. 
 
 I was desired to visit a gentleman, who, 
 after acute rheumatism, had a diseased knee, 
 which measured more than the other by 
 three inches and a half. Fluid was to be 
 felt fluctuating on each side of the joint, 
 and under the knee-pan, which was eleva- 
 ted considerably above the thigh-bone, and 
 which, by motion, was distinctly heard to 
 grate This patient felt much uneasiness 
 within the articulation of the knee, for 
 some time before the joint enlarged, and his 
 health was very much impaired. 
 
 The caustic was applied on each side of 
 the joint, and the sores were kept open by 
 the sponge ; an artificial drain was kept up, 
 either in this way, or by previously blister- 
 ing, and afterwards dressing with the sa- 
 vin e cerate, for the space of nearly twelve 
 months, with manifest advantage ; for his 
 health was restored, he was enabled to walk 
 without pain, though the joint felt weak. 
 
( 151 ) 
 
 and appeared somewhat swollen ; and, on 
 motion, no grating could be perceived, yet 
 the patella appeared to be increased in its 
 circumference. I cannot give any further 
 account of this case as the vocations of the 
 gentleman carried him out of town. 
 
 CASE XV. 
 
 A. M. about the age of twenty-two, 
 called on me, on account of a diseased 
 knee, with which he had been afflicted for 
 nearly two years ; and v^hen it first ap- 
 peared, the pain was removed by blistering, 
 but it soon after returned. The joint was 
 much enlarged ; but so tense and hard was 
 the part, that it appeared to a medical friend 
 and myself, that the condyles were en- 
 larged ; and from the deep pain he felt in 
 the cavity of the joint, when it was used, 
 we concluded also that the ligaments had 
 suffered. This person's joint was treated, 
 for four months, in the same way as has 
 been mentioned in the preceding case, and 
 with the like success, and the joint is now 
 
( 152 ) . 
 
 of its natural size. Though several months 
 have elapsed since the cure was performed, 
 he continues well, and enjoys a remarkably 
 good state of health. 
 
 CASE XVI. 
 
 C. B. a young woman of a strumous 
 habit, had felt for some months, great pain 
 on each side of her knee, and under the 
 knee-pan, which was followed by swelHng; 
 and when this effect took place she became 
 easier. This patient also had night-sweats, 
 fever, and loss of appetite ; the joint was 
 enlarged, puffy, and of a pallid hue. A 
 blister was applied, which completely co- 
 vered its anterior and lateral parts, and when 
 the cuticle had been removed, the sore was 
 daily dressed with the ceratum sabinae, for 
 about three weeks ; when the sores were 
 suffered to heal, excepting in those places 
 where the pain first originated. She also 
 had some scrofulous sores on the other leg, 
 which kept mending as long as a discharge 
 
( 153 ) 
 
 was kept up from the diseased knee ; but 
 when the sore was healed, in consequence 
 of the joint having recovered, the ulcer 
 became worse. This circumstance induced 
 me to cut her an issue above the knee, 
 which I understand is kept open, and she 
 has had no relapse. 
 
 CASE XVII. 
 
 A child, about two years old, with en- 
 larged glands of the neck, had suffered 
 from a white- swelling of the knee, for 
 about three months ; the joint was twice 
 its natural size, and the child cried much 
 when it was moved. The mother, pre- 
 viously to her discovering the part to be 
 swollen, noticed that the infant could not 
 bear this joint to be exercised w^ith the 
 same freedom as the other. The integu- 
 ments were pale and thickened, but not 
 oedematous. A blister was applied suffi- 
 ciently large to cover the anterior and 
 lateral parts of the knee, and when the 
 cuticle was removed, the joint was covered 
 
( 154 ) 
 
 with a dressing of the savine cerate, which 
 kept the part discharging very copiously 
 for about three months, in which time, the 
 joint completely recovered, and was in 
 every respect as useful as the other ; the 
 swelling of the glands of the neck also 
 subsided, under the same treatment. 
 
 CASE XYIII. 
 
 I. C. between twenty and thirty, of a 
 scrofulous habit, was attacked very sud- 
 denly, with a violent pain within the joint 
 of his knee, which he described as shooting 
 from each side, and under the knee-pan, 
 into the interior part of the articulation. 
 He applied to me a few days after this 
 attack, when the whole of the joint was 
 much swollen, and the pain, on motion, 
 very excruciating ; twelve leeches were ap- 
 plied, which bled freely, and the part was 
 frequently fomented ; but no relief was 
 obtained from this treatment. A large 
 blister was applied, and a very great dis- 
 charge was maintained by the use of the 
 
( 155 ) 
 
 savine cerate, for above a month ; when 
 he lost all pain, and the joint was reduced 
 to its natural size, although considerably 
 weakened. It ought to be mentioned, that 
 this patient was not relieved by the first 
 eiFect of the blister, and indeed, not till 
 after a discharge had been kept up for 
 several days. I have frequently seen this 
 person since, and the joint remains perfectly 
 well, and as useful and as strong as the 
 other. 
 
 CASE XIX. 
 
 W. C. had been afflicted twelve months 
 with a diseased elbow; he felt great pain 
 within the articulation, and in the condyles 
 of the OS humeri, for some time previously 
 to the joint appearing enlarged. About 
 seven months after the elbow had been dis^ 
 eased, his knee became affected, and this 
 complaint was preceded by excruciating 
 pain, first in his hip, and which (to use his 
 own expression) fell into his knee, and 
 there continuing for some time, the joint 
 
( 156 ) 
 
 began to swell. When I saw this patient, 
 he complained of violent pain in his side, 
 had haemoptysis, cough, and night-sweats ; 
 his elbow had ulcerated in three places, and 
 discharged freely ; and, though there was a 
 quantity of fluid accumulated about the joint, 
 the condyles appeared enlarged, and when 
 the elbow was moved, the bones grated. 
 The knee was contracted, much swollen, 
 and so distended, that till after the reduc- 
 tion of the swelling, I was unable to ascertain 
 that the end of the thigh-bone was enlarged, 
 though he experienced much uneasiness in 
 the cond}/les, and within the cavity of the 
 joint. In consequence of the w^eak state of 
 the patient, I was contented to try what 
 would be the effect of a purulent drain de- 
 rived from the knee only. After the part 
 had discharged freely for about a fortnight, 
 he did not expectorate any more blood ; his 
 complaints in his chest were greatly re- 
 lieved, and in a few weeks were entirely 
 removed. The improved state of this pa- 
 tient's health was an encouragement to 
 treat the elbow in the same way, and an 
 
( 157 ) 
 
 artificial drain was procured, first by blis- 
 tering, and afterwards dressing with the 
 savine cerate, for nearly a year. The 
 elbow remains contracted, and when it is 
 moved, no grating is perceptible; the ulcers 
 have gradually healed, and, excepting an 
 enlargement of bone, there is no appear- 
 ance of disease. 
 
 The knee became free from pain, and 
 perfectly recovered its motion, though the 
 joint was an inch in circumference larger 
 than the other, a circumstance clearly at- 
 tributable to an increased size of the con- 
 dyles. 
 
 This patient is of a scrofulous habit, and 
 the disease of the knee has once returned; 
 the same treatment was again resorted to, 
 and, excepting the joint being very consi- 
 derably weakened, it remains in the state 
 just described ; but with a view to prevent 
 any further relapse, a common issue has 
 been made above the knee. 
 
( 158 ) 
 
 CASE XX. 
 
 A hoy, aged seven years, had a diseased 
 knee and ankle-joint of the same limb, 
 which had so impaired his health, that 
 amputation was thought adviseable, but to 
 this the parents would not consent. The 
 knee-joint having been first affected, and 
 advancing fast to a state of suppuration, it 
 was blistered, and the part was every day 
 dressed with the savine cerate, for above 
 six months; this treatment produced a re- 
 duction of the swelling of the soft parts, a 
 removal of the pain occasioned by the dis- 
 ease, and a complete absorption of the fluid, 
 with which the diiferent parts of the joint 
 had been distended. 
 
 The knee is capable of every function, 
 though the condyles of the thigh-bone re- 
 main considerably enlarged. 
 
 From the improvement of the boy's 
 health, and the amendment of his knee, I 
 
( 159 ) 
 
 recommended the ankle-joint to be treated 
 in the same way ; but with what advan- 
 tage, I have not yet heard, as he resides 
 in the country. 
 
 CASE XXI. 
 
 E. P. eleven years old, of a scrofulous 
 family, had an indolent white- swelling, 
 for about four years ; the joint was much 
 swollen, the integuments were thickened, 
 but not oedematous, and the skin was re- 
 markably pallid. This boy was suffering 
 much from the painful state of the part, the 
 disease was making rapid progress, and he 
 could not, as before, bear it to be handled 
 without great complaint, and in moving the 
 joint, he expressed a sensation of much un- 
 easiness within the articulation. A blister 
 was applied over the whole knee, and was 
 kept discharging with the savine cerate for 
 about two months, by which treatment he 
 perfectly recovered, though the joint for 
 some time remained weak: it is almost two 
 
( 160 ) 
 
 years since, and no symptom of disease has 
 appeared. 
 
 CASE xxir. 
 
 A. D. of a scrofulous habit, some days 
 after a fall, which at the time did not oc- 
 casion any inconvenience, complained of a 
 dreadful pain in the inside of his knee, 
 which was followed by a puffy swelling, 
 under and on each side of the knee; he 
 could bear the part to be handled with free- 
 dom, provided the limb was at rest, without 
 manifesting any increase of uneasiness ; but 
 when the joint was moved, his sufferings 
 were severe. Six leeches were first applied 
 without affording any relief, a blister was 
 therefore had recourse to, and the sore was 
 dressed with the savine cerate for about 
 three weeks, in which time, a very copious 
 discharge was kept up, the pain gradually 
 subsided, and the joint has remained in a 
 perfect and healthy state. 
 
( 161 ) 
 
 CASE XXIII. 
 
 I. S. aged sixteen, had for several months, 
 prior to his application to me, suffered great 
 pain within the joint of his knee, before the 
 part began to swell; he could then bear it 
 to be handled without increase of pain ; but 
 his using the joint in any waj, occasioned 
 great uneasiness, and his sufferings were 
 somewhat diminished after the tumefaction 
 appeared. When I saw him, the joint was 
 much distended, and he felt a deep-seated 
 pain within the articulation, which affected 
 his health. 
 
 A blister was first applied to the knee, 
 and when the cuticle was removed, the part 
 w^as dressed with the savine cerate for six 
 months, when he had lost all pain, and the 
 joint in every respect appeared sound, 
 though it was weak for some time. 
 
 , He remained well for six months, and 
 when he relapsed, the same sort of treat- 
 
 M 
 
( 162 ) 
 
 ment, with success, was resorted to; but, 
 in this instance, twice the time was requi- 
 site for his recovery : and to prevent another 
 relapse, as he was of a scrofulous constitu- 
 tion, an issue was made above the knee, 
 and he has remained well almost twelve 
 months. 
 
 CASE XXIV. 
 
 H. W. aged thirty, was seized, about 
 four years ago, with pain in the condyles 
 of the thigh-bone, and within the articula- 
 tion ; her case was treated and looked upon 
 as rheumatism, as the joint became easier 
 when used, but more stiff and painful, after 
 the limb had been at rest for some time. 
 She began to suffer in her health, which 
 was afterwards much improved by being at 
 the sea-side; she went frequently into a 
 warm sea-bath, with the advantage only of 
 relaxing the joint, but it did not reduce the 
 swelling, or remove the pain. Different 
 liniments and plaisters were applied, and 
 
( 163 ) 
 
 she underwent a long course of mercury, 
 without the smallest relief. 
 
 It is now more than twelve months since 
 I first saw her, and by submitting to the 
 treatment mentioned in the preceding case, 
 she has a very useful limb; can extend, but 
 is unable to bend it so perfectly as she can 
 the other knee. Her health is verj good- 
 she is free from those pains, by which she 
 had been before oppressed, and the swel- 
 ling of the soft parts is completely removed. 
 Her complaint being of long standing, and 
 her pains having begun in the condyles, 
 which remain enlarged, I have thought it 
 advisable to keep up a discharge for some 
 time longer on each side of the joint, and 
 ultimately mean to make an issue above the 
 knee. 
 
 CASE XXY. 
 
 A maid-servant in my neighbourhood, 
 about seventeen years of age, had for many 
 months been afflicted with a pain within thg 
 M 2 
 
( 164 ) 
 
 articulation of the knee, before the joint 
 appeared at all enlarged. In the incipient 
 stage of the complaint, she could bear the 
 part to be handled without any additional 
 uneasiness, but moving the joint in any 
 v^ray, greatly increased her sufferings. Af- 
 ter the first appearance of enlargement, she 
 became somewhat easier, but when the 
 swelling had very considerably increased, 
 and the joint become much distended by 
 fluid collected in the different parts of it, 
 handling then became very uneasy to her, 
 and the pain within the articulation was 
 particularly severe, indeed so much so, that 
 opium was given every night, to procure 
 sleep. 
 
 The anterior and lateral parts of the 
 knee were blistered, and the cuticle being 
 removed, the sores v^ere dressed every day 
 with the ceratum sabin^. After a dis- 
 charge had continued for some days, she 
 became easier, the opium was therefore 
 omitted, and in about a month the pain 
 and swelling entirely subsided; the joint 
 
( 165 ) 
 
 in every respect recovered, and remains 
 well. 
 
 CASE XX7I. 
 
 A young lady, aged twelve years, was 
 brought to me, from the country, to be put 
 under my care. She had a diseased ankle- 
 joint, of the indolent sort, the appearance 
 of which I have so often described ; it had 
 suppurated on the inner side, but the ulcer 
 did not reduce the general swelling, and 
 only seemed to affect that part over which 
 it was immediately situated. A blister was 
 applied round the whole joint, but the ul- 
 cerated part was defended by a dressing of 
 of white cerate, a discharge was kept up 
 for six months, in the manner T have re- 
 commended, and the success of the practice 
 was most decisive. From her constitu- 
 tional tendency to scrofula, I made an issue 
 above her knee, and directed that it should 
 be constantly kept open. I consider this 
 treatment as having prevented the recur- 
 
( 166 ) 
 
 rence of any modification of the disease 
 since that time. 
 
 CASE XXYII. 
 
 W. B. thirty-four years of age, of a scro- 
 fulous habit, had an affection of the left 
 ankle-joint, after external injury, which at 
 last increased so as to render him incapable 
 of following his ordinary occupation of a 
 farrier. He was for some time admitted a 
 patient in a hospital, without receiving any 
 benefit, though all the ordinary methods of 
 treatment were employed. It is now more 
 than three years since he applied to me; 
 the joint was much swollen, and was re- 
 markably tense, though a fluctuation was 
 perceptible in some parts; he complained 
 of a violent deep-seated pain within the 
 joint, and it was completely useless. I first 
 directed leeches, and then applied a blister 
 over the joint, intending to maintain a per- 
 manent discharge by the common blister- 
 ointment ; but the strangury which super- 
 l^ened, made it necessary for me to desist 
 
( 167 ) 
 
 from its use. I therefore made a large 
 eschar on each side of the joint, from 
 which a drain was established for more 
 than a year and a half: it became free from 
 pain and swelling, and though it is less 
 flexible and strong than the other, he is 
 nevertheless enabled to follow his business, 
 which the disease had previously obliged 
 him to quit. 
 
 CASE XXVIII. 
 
 E. S. about six years of age, of a stru- 
 mous habit, and labouring under phthisis 
 pulmonalis, was brought to me, for an in- 
 dolent white-swelling of the elbow; the 
 joint was twice its natural size, and a fluc- 
 tuation of fluid was evidently to be felt. 
 
 The whole joint was surrounded by a 
 blister, and when the cuticle was removed, 
 the part was dressed with the savine cerate. 
 The advantages first derived from this treat- 
 ment, were effectual in recovering the pa- 
 tient's health, as his breathing became 
 
( 168 ) 
 
 easier, and his night-sweats, cough, and 
 pain in the side were entirely removed. 
 
 The diseased joint gradually recovered 
 in about twelve months, and was com- 
 pletely cured; an issue was at that time 
 made in the arm, and the child in every 
 respect has since continued well, a period 
 of about a year. 
 
 CASE XXIX. 
 
 A case of a diseased elbow occurred in a 
 scrofulous girl, about the age of fifteen, 
 nearly similar in appearance to the case 
 just recited, excepting that the arm was 
 in an extended state, and the joint so rigid, 
 as to be incapable of the least flexion, 
 though it admitted a degree of motion 
 sufficient to prove that its rigidity was 
 not owing to ossific union. By a drain of 
 several weeks' continuance, the disease of 
 the joint got well, and the limb was per- 
 fectly restored to its functions. 
 
( 169 ) 
 
 CASE XXX. 
 
 I shall now mention a case, in which, 
 though it is not yet terminated, the altera- 
 tion produced, has been as marked as I 
 could wish: it was an elbow disease. The 
 condyles were much enlarged, the integu- 
 ments were become thin in one part, and 
 a general fluctuation could be perceived; 
 there was an ulceration with considerable 
 fungus, and a discharge of a viscid glairy 
 matter in small quantity, upon that part 
 where the integuments were thinest. Dry 
 lint was applied immediately to the fungus, 
 and then the joint w^as surrounded by a 
 blister. A discharge has been persevered in 
 for six months, the general health, which 
 had always been bad, seems from the mo- 
 ther's account, to be very much improved. 
 That part of the swelling which depended 
 on fluid, has disappeared ; the fungus has 
 subsided, so that at present, the discharge 
 is kept up from the surface even of the 
 whole joint, and the only disease which 
 
( 170 ) 
 
 seems to remain, consists in the enlarge- 
 ment of the bones. 
 
 CASE xxxr. 
 
 A gentleman, of a scrofulous habit, had 
 a diseased knee, for the relief of which 
 cupping and leeches were frequently re- 
 sorted to, and as soon as ease was procured, 
 the joint was blistered on each side, and 
 the discharge maintained by the savine ce- 
 rate. The effect of this treatment was a 
 gradual absorption of the fluid effused within 
 the articulation, with a reduction of the 
 swollen condition of the integuments. 
 
 The friends of the patient became uneasy 
 about him, and solicitous that another opi- 
 nion should be had respecting his case, and 
 a surgeon of eminence was selected. The 
 result of this consultation was to heal the 
 blistered surface, apply the emplastrum 
 gummi ammoniaci cum hydragyro over the 
 knee, and persist in taking the decoction of 
 cinchona with the natron preparatum. This 
 
( 171 ) 
 
 advice was followed. The joint within a 
 fortnight became very considerably en- 
 creased in size, and a lage collection of 
 fluid had formed itself under the fascia. 
 The patient was feverish and nmch weak- 
 ened ; I removed the plaister, and covered 
 the joint with the saturnine lotion, and 
 passed a roller from above downwards 
 towards the knee, a little above which 
 finding the fluctuation very distinct, I dis- 
 charged by a small trocar, a pint of sero- 
 purulent fluid. This operation was repeated 
 at the interval of every other day for three 
 times. 
 
 Of this part of his complaint he com- 
 pletely recovered, but his health and 
 strength were so greatly reduced, that I 
 sent him a little way out of town. He 
 improved so much in a few weeks that I 
 was induced to apply a caustic issue on 
 each side of the joint of the size of a crown 
 piece : the discharge was kept up nearly the 
 space of a year and a half. He then went 
 by sea into the north, where his friends 
 reside, from whom I have heard of hi$ 
 
( 172 ) 
 
 recovery, and was much pleased in being 
 assured that the motions and use of the 
 joint are not perceptibly diminished, and 
 the issues were still discharging. When I 
 last visited him I expected nothing less 
 than a stiff extended limb. 
 
 CASE XXXII. 
 
 Master , aged five years, applied to 
 
 Mr. Langstaff on account of a diseased 
 elbow-joint. The integuments were not 
 discoloured, but very hot ; and he com- 
 plained of pain when the joint was moved, 
 or the external condyle was pressed upon. 
 
 The antiphlogistic treatment^ with the 
 frequent application of leeches, was strictly 
 attended to for upwards of six weeks. The 
 joint at this time had undergone no dimi- 
 nution of swelling, but the h^at and pain 
 had entirely subsided, though the integu- 
 ments felt much thickened and so tense as 
 not to allow of their being pinched up. A 
 blister was applied on each side of the joint. 
 
( 173 ) 
 
 and after the cuticle was removed the sur- 
 face was dressed with equal portions of the 
 ceratum sabinae and spermaceti ointment. 
 After three days use of this appUcation a 
 purulent discharge was established, but 
 the pain and inflammation obliged Mr. 
 Langstaff to dress the part with the sper- 
 maceti cerate, and to apply leeches and 
 evaporating lotions, under which treatment 
 the blistered surfaces healed. At the end 
 of three weeks the joint was again blistered, 
 and the discharge was maintained by equal 
 proportions of the savine and spermaceti 
 cerate. The patient began to complain of 
 pain in the anterior part of the elbow near 
 its articulation with the radius, where, in a 
 few days, a tumor, about the size of a pul- 
 let's egg, appeared, pointed and burst, and 
 the matter discharged was of a scrofulous 
 curdly kind ; on the introduction of a probe 
 into the opening it was found to communi- 
 cate with the joint, but the bones were not 
 denuded of their cartilage. A dressing of 
 spermaceti cerate was applied to the abscess, 
 and the blistered surfaces were kept dis- 
 charging six months. At this period the 
 
( 174 ) 
 
 complaint of the joint was entirely removed, 
 but fomentations, oily frictions, and gentle 
 exercise were employed until the use of the 
 part was restored. The boy's father died 
 of pulmonary consumption : upon opening 
 the body his lungs were found replete 
 with scrofulous tubercles, and the lumbar 
 and mesenteric glands enlarged and indu- 
 rated 
 
 Cases of supposed Enlargement of the Bones, 
 
 An opportunity has been afforded me of 
 acquainting the profession with two other 
 cases of knee affection, in which I had given 
 my opinion that the slight enlargement of 
 the joint, which was left, was owing to an 
 increase of size in the bone, but they prove, 
 on subsequent examination, to be other^ 
 ivise. Mr. Langstaff, a surgeon of ex- 
 perience, zealous for the advancement of 
 the science, can bear testimony, that in 
 one case the condyles of the femur are 
 considerably diminished, and the size of 
 the joint is less th^n the healthy one by 
 
( 175 ) 
 
 an inch and a half. The other instance 
 is the second case I pubhshed in my former 
 edition, and aUhough I then stated that 
 there remained a shght enlargement of 
 the inner condyle, there is now scarce a 
 vestige of its existence. After the reco- 
 very of the joint, a little thickening of parts 
 sometimes remains ; the size of a nutmeg, 
 of the following volatile mercurial liniment 
 rubbed in night and morning, has been 
 found serviceable in removing it, previously 
 fomenting the joint with warm water: 
 
 R. Unguenti Hydrargyri fortioris uaciam unam 
 Adipis suillae uncias duas 
 Camphoras dracmas duas 
 Spiritus vini rectificati q. s. 
 Aquae ammoniae purse unciam. 
 Camphorae spiritu vinoso solutae adde aquara ammonige et 
 unguentum prius cum adipe coramixtum. 
 
 From the observations which have been 
 made, and the cases adduced, I think my- 
 self justifiable, in drawing the following 
 conclusions ; 
 
 That long-continued discharges, artifi- 
 cially excited, are highly beneficial in cases 
 
( 176 ) 
 
 of white-swelling, and in various other'mo- 
 difications of scrofula. 
 
 That caries has been arrested, and some- 
 times cured ; that collections of fluid within 
 the cavities of joints, or exterior to them, 
 have been removed ; that sores connected 
 with the local affection have been perma- 
 nently healed, and a repetition of them 
 prevented ; that the general health of every 
 patient has been strikingl}' improved, and 
 that where this treatment has been adopted 
 in consequence of the diseased joint, other 
 scrofulous appearances in distant parts have 
 also yielded to it. 
 
 That the best method of producing such 
 discharge, is the application of a common 
 blister in the first instance, and when the cu- 
 ticle has been removed, by dressing the part 
 with the savin e cerate ; and that the use of 
 this preparation may be beneficially extended 
 to a great variety of cases, where a copious 
 local discharge may be thought advisable. 
 
 That an issue in any part of the body. 
 
( 177 ) 
 
 may be successfully employed, as a consti- 
 tutional remedy, in all cases of scrofula, 
 and may probably be sufficiently powerful, 
 when it is applied in time, to prevent an 
 attack of this disease, in constitutions pre?- 
 disposed to it. 
 
 And finally, that we are not to be de- 
 pressed by the obstinate resistance of the 
 complaint, or lose the necessary confidence 
 in our mode of treatment, although months 
 should pass without much apparent advan- 
 tage ; for it has principally been owing to 
 a steady perseverance, that I have succeeded 
 in restoring some patients, labouring under 
 unfortunate and almost desperate diseases, 
 to the full enjoyment of their health. 
 
 N 
 
( 178 ) 
 
 SECTION IX, 
 
 Necrosis. 
 
 I HAVE been induced to give this subject a 
 place in the present work, not on account 
 of any analogy which the disease bears to 
 white- swelling, but because experience has 
 taught me, that however dissimilar the two 
 maladies may be, yet the treatment, which 
 they both require, is the same, with very 
 little modification. 
 
 Necrosis, or the death of a bone, is a very 
 different affection from any other disease of 
 these organs. 
 
 Surgical observers have published several 
 cases, in which a large portion of the whole 
 substance of a bone has been removed, and 
 the place of the lost portion supplied by a 
 new bony cylinder; yet the manner, int. 
 
( 179 ) 
 
 which this was effected, has, until of late 
 years, been very imperfectly understood. 
 The complaint was regarded as a species of 
 caries ; and surgeons supposed that the 
 renewal of the bone was effected by callus. 
 If the term necrosis were unknown to 
 Meekren, yet he noticed, with consider- 
 able accuracy, the principal phenomena oc- 
 curring in this complaint, as the substitution 
 of a new bone in place of the original dead 
 one, and the subsequent enjoyment of full 
 power and use of the limb. I will give his 
 own. words, which contain a clear and ex- 
 plicit statement of these facts : — " Alte- 
 rum hie considerandum naturae providentiam 
 spectat, qua ablatae partis in locum ea re- 
 ponere observatur, quorum ope actio requi- 
 sita exerceri queat. Ita notare nobis licuit 
 in milite quodam anglo femoris os totum 
 abscessu consumptum, et ablatum fuisse, et 
 tamen incessum neutiquam laesum, eo quod 
 in locum deperditi substantia alia regene- 
 rata."* 
 
 * Jobi a Meekren Obseivationes Medico-Chirurgicae;, p. 
 332, cap, Ixix. 
 
 N 2 
 
( 180 ) 
 
 The author refers us to the observations 
 of HiLDANUs and others ; and the records 
 of surgery on this subject have been largely 
 increased by subsequent writers, whose 
 labours I think it unnecessary to refer to, 
 as the disease may be sufficiently under- 
 stood by the observation or perusal of a few 
 cases. The old and dead bone has been 
 called sequestra, and as the osseous cylinder 
 is formed on the outside of the former, its 
 external dimensions must of course exceed 
 those of the old bone. Its appearance and 
 texture are also very unlike those of the 
 original, being more hard and compact in 
 substance, and rough and irregular on its 
 surface. Indeed the only point of resem- 
 blance between the two parts is their length. 
 The articular ends of the bones are not af- 
 fected by necrosis ; it is their diaphysis 
 only, or that part which is situated between 
 the epiphyses, which, in a former section 
 of this work, I have called the internodial 
 portion of a bone. 
 
 No subject in the whole circle of patho- 
 logy affords a more obvious and convincing 
 
( 181 ) 
 
 proof of the vast powers of nature in re- 
 medying the effects of disease than the pro- 
 cesses which occur in the various stages of 
 necrosis. We must be led to place the 
 greatest confidence in her resources, when 
 we see the whole body of the thigh bone 
 perish, and then become surrounded by a 
 newly formed tube, which absorbs the dead 
 part, and preserves the figure and motions 
 of the limb unimpaired. The latter circum- 
 stance has particularly attracted the. atten- 
 tion of practitioners, and has been consi- 
 dered by them as a subject of difficult 
 explanation. A case in which about two- 
 thirds of the lower jaw perished, with a 
 very slight interruption of the motions of 
 the part, drew from the author the fol- 
 lowing observations, containing an obscure 
 hint towards the true method of accounting 
 for the phenomena of necrosis. " Cette 
 derniere observation sembleroit prouver qu'il 
 y a eu reparation de la substance osseuse 
 par des sues auxquels le perioste auroit 
 servi de moule, et dont il a pu fournir 
 une partie. La nature mieux connue que 
 du temps de nos predecesseurs nous a 
 
( 182) 
 
 montre ses resources d'une maniere si evi- 
 dente, en cas analogues a celui-ci, qu'on 
 ne peut plus former de doutes, sur son 
 operation favorable et vraiement digne 
 d'admiration."* 
 
 As my own practice and opportunities 
 have not furnished me v^^ith the means of 
 investigating the changes, which take place 
 in a case of necrosis, I consider myself as 
 particularly fortunate in being able to com- 
 municate to the public, an original and 
 very satisfactory account of the subject, in 
 a letter from my friend Mr. Macartney. 
 The abilities of that gentleman are too well 
 known, and too generally admitted to need 
 the aid of my feeble eulogium. I shall 
 only state, that I consider the following 
 observations on necrosis to be a very suc- 
 cessful application of those abilities to the 
 elucidation of a most important and highly 
 interesting pathological phenomenon. 
 
 *" Mcmoires de rAcademie Royale de Chiruigie, vol. V. 
 p. 358. 
 
( 183 ) 
 
 " Dear Sir, 
 
 " The observations I spoke of 
 having made upon necrosis related to the 
 changes of structure which attend the pro- 
 gress of that complaint, and vs^hich, as far 
 as I am informed, have not been accurately 
 described by any writer upon the subject. 
 
 " It happened a few years ago, that a num- 
 ber of ^specimens of necrosis came into my 
 hands, and some of them at very early 
 periods of the affection; after having in- 
 jected these with colored fluid, I was en- 
 abled to trace the proceedings of the disease 
 from its commencement. I found that the 
 first and most important circumstance is the 
 change, which takes place in the organiza- 
 tion of the periosteum ; this membrane 
 acquires the highest degree of vascula- 
 rity, becomes considerably thickened, soft, 
 spongy, and loosely adherent to the bone ; 
 the cellular substance also, which is imme- 
 diately connected with the periosteum, suf- 
 
( i^4 ) 
 
 fers a similar alteration : it puts on the 
 appearance of being inflamed, its vessels 
 enlarge, lymph is shed into its interstices, 
 and it becomes consolidated with the pe- 
 riosteum. These changes are prepara- 
 tory to the absorption of the old bone, and 
 the secretion of new osseous matter, and 
 even previous to the death of the bone 
 which is to be removed. In one instance 
 I found the periosteum vascular and pulpy, 
 when the only affection was a small abscess 
 of the medulla, the bone still retaining its 
 connexion with the neighbouring parts, as 
 it readily received injection. The newly 
 organized periosteum, which, for the sake 
 of distinction, one might call the vascular 
 sheath or investment, separates entirely from 
 the bone, after which it begins to remove the 
 latter by absorption, and during the time that 
 this process is carrying on, the surface of 
 the vascular investment, which is applied 
 to the bone, becomes covered with little 
 eminences, exactly similar to the granula- 
 tions of a common ulcer. 
 
 '* In proportion as the old bone is removed. 
 
( 185 ) 
 
 new osseous matter is dispersed in the sub- 
 stance of the granulations, whilst they con- 
 tinue to grow upon the old bone, until the 
 whole or a part of it is completely ab- 
 sorbed, according to the circumstances of 
 the case. 
 
 ** What remains of the investment, after 
 the absorption of the old bone, and the 
 formation of the osseous tube, which is to 
 replace it, degenerates, loses its vascularity, 
 and appears like a lacerated membrane. I 
 never had an opportunity of examining a 
 limb, a sufficient time after the natural ter- 
 mination of the disease, to ascertain whe- 
 ther the investment be at last totally ab- 
 sorbed, but in some instances I have seen 
 very little remaining. During the progress 
 of the disease, the thickened cellular sub- 
 stance, which surrounded the original peri- 
 osteum, becomes gradually thinner; its ves- 
 sels diminish, and it adheres strictly to the 
 new formed bone, to which it ultimately 
 serves as a periosteum. 
 
 " The most striking peculiarity in the his- 
 
( 186 ) 
 
 tory of necrosis, you will then perceive to 
 be, the conversion of the periosteum into 
 an organ possessing active powers of ab- 
 sorbing and secreting bone : the structure 
 of granulations seems to be best calculated 
 for performing these offices, as we find it 
 employed for the same purposes on other 
 occasions. 
 
 " Thus it is vrell known, that the granu- 
 lations, which are interposed between the 
 two ends of a bone, in cases of a compound 
 fracture, become ossified ; and I have ob- 
 served, that the detachment of carious bones 
 in external ulcers, is effected by the granu- 
 lations of the sore, working their way from 
 the edges, absorbing indifferently the sound 
 and dead bone, until the separation of the 
 latter be complete. 
 
 " I am, dear Sir, 
 
 " Yours, &c. 
 
 " JAMES MACARTNEY. 
 
 '' P. S. The anatomical preparations, whicli 
 
( 187 ) 
 
 authenticate the above observations, are 
 preserved in the collection of St. Bartholo- 
 mew's hospital." 
 
 I shall trespass shortly on my reader's 
 time, by noticing some opinions of modern 
 writers on the subject of necrosis. 
 
 Mr. Bell says, in his System of Surgery, 
 '* We would naturally suppose, that those 
 tendons of muscles, which were originally 
 inserted into that portion of the old bone, 
 that is now destroyed, would completely 
 lose their influence : but it is quite other- 
 wise ; for we find, that they possess their 
 relative situation in the newly-formed bone, 
 into which they are inserted by the ossifi- 
 cation of a gelatinous fluid poured forth 
 around them."* The reason why the mus- 
 cles lose not their attachment, is from 
 their connexion with the periosteum ; the 
 change, which this membrane undergoes, 
 Mr. Macartney has most satisfactorily ex- 
 plained. 
 
 * Vol. VII. p. 216, rth edit. 
 
( 188 ) 
 
 Mr. Russell, of Edinburgh, has taken 
 great pains, in an Essay on Necrosis, to 
 prove, that the periosteum of the original 
 bone, has no share in the formation of the 
 new osseous cylinder. According to this 
 gentleman, " the first step of the process 
 is to surround the old bone with an effu- 
 sion, which seems to be of a gelatinous 
 nature."* The description, which he pro- 
 ceeds to give of this newly deposited sub- 
 stance, corresponds very much with Mr. 
 Macaktney's account of the changes effect- 
 ed in the periosteum and surrounding parts ; 
 so that, although the mode of accounting 
 for the change is somewhat different, the 
 essential facts and observations are nearly 
 the same. 
 
 Mr. Russell's arguments against assign- 
 ing to the periosteum any share in the pro- 
 duction of the new bone, do not appear to 
 me at all direct or convincing. I shall 
 quote his own words, to enable the reader 
 to judge for himself on this subject. 
 
 Essay, p. 7* 
 
( 189 ) 
 
 " But upon this foundation, the growth 
 of the osseous shell has been imputed 
 solely to the extension of the periosteum, 
 and to the deposition of osseous particles 
 in the heart of its substance, or between 
 its layers. According to this latter sup- 
 position, that the bony matter is deposited 
 between the layers of the periosteum, the 
 new osseous shell should derive a compleat 
 covering from the original periosteum, both 
 on its inner and outer surface. That this, 
 however, is not the fact, appears from an 
 examination of parts, w^hile they are form- 
 ing. It is then evident, that ossific gra- 
 nulations arise, both from the internal and 
 external surface of the new osseous shell, 
 but on neither of the surfaces does the 
 smallest vestige of a covering, derived from 
 the original periosteum, make its appear- 
 ance. Indeed, this idea seems to me 
 wholly incompatible with the inequalities 
 of both surfaces : for, if two layers of pe- 
 riosteum were distended by the interpo- 
 sition of ossific matter between them, 
 both surfaces would then be smooth along 
 the wjiole of the extent: yet, thati the 
 
( 190 ) 
 
 direct contrary takes place, is apparent 
 from the slightest examination of appear- 
 ances. Besides, in those cases, where the 
 sequestra is removed, and consequently 
 does not limit the extension of the new 
 bone internally, the whole space fills up, 
 and the cavity is totally obliterated along 
 with the supposed investing periosteum. 
 Yet, surely, this obliteration could not pos- 
 sibly happen, if the internal surface of the 
 new bone were fortified with a new lining 
 from the original periosteum." 
 
 It must appear very clearly, that none 
 of this reasoning will apply to Mr. Macart- 
 ney's observations. That gentleman says 
 nothing of the layers, or the heart of the 
 substance of the periosteum. He. only adr 
 mits a great and general change in its tex- 
 ture, adapting it for a most important and 
 beneficial purpose in the animal economy, 
 -^the formation of a substitute for the dead 
 bone. He expressly states, that on the in- 
 ner surface of the new tube, it assumes the 
 form of granulations, which absorb the se- 
 questra. None of his observations afford 
 
( i9i ) 
 
 any reason for inferring, that the outer sur- 
 face should be either uniform or otherwise; 
 but we should undoubtedly have concluded 
 a priori, from the analogy of all instances 
 of deposition of new bony matter, as we 
 find to be actually the case in this instance, 
 that it would present a rough and irregular 
 appearance. 
 
 *' And further," says Mr. Russell, " in 
 all cases of necrosis, the new bone in its 
 incipient state is on its outside so blended 
 with the neighbouring part, that it is im- 
 possible to distinguish and separate them 
 from each other; whereas, if the new bone 
 still remained encompassed on its outside 
 with the external layer of the original pe- 
 riosteum, the separation of parts would be 
 distinct and easy. Indeed, the want of 
 this distinctness is almost a proof that no 
 covering is derived from the original peri- 
 osteum." 
 
 Here we have a just observation of a fact 
 applied to prove a point, with which it has 
 no connexion. The cellular substance, and 
 
( 192 ) 
 
 muscular and tendinous parts surrounding 
 a bone, that has suffered necrosis, become 
 thickened and indurated: thej are indeed all 
 massed and confused together, and consoli- 
 dated into a tough substance of a cartilagi- 
 nous or tendinous hardness. These ap- 
 pearances must undoubtedly be referred to 
 the severe and long continued inflammation, 
 which forms a striking feature in every case 
 of necrosis ; and which is kept up in a 
 greater or less degree by the irritation of 
 the complaint to its complete termination. 
 I can by no means discern how this cir- 
 cumstance can at all affect the question, 
 whether the periosteum be or be not con- 
 cerned in forming the new bone. 
 
 The appearances in certain cases of com- 
 pound fracture are also adduced in further 
 proof of Mr. R's opinions.* A process 
 similar to necrosis is sometimes observed in 
 these injuries. I cannot discover, by an at- 
 tentive perusal of the arguments on this 
 subject, that they prove, that the new bone 
 
 might not have been furnished by the peri- 
 
 * P. 18 to 21. 
 
( 193 ) 
 
 osteum ; and in a specimen, which I have 
 examined myself, there is every appearance 
 that the new deposit was actually formed 
 by that membrane. 
 
 The instance of simple fracture, related 
 at page 22, as well as the other examples 
 of a formation of new bony substance in- 
 dependently of the periosteum, in other 
 injuries of bones, alluded to in the same 
 section, are altogether foreign to our present 
 subject; which is a discussion of the ques- 
 tion, how far the periosteum is concerned 
 in the formation of the new bone in a case 
 of necrosis. 
 
 I do not deny, nor have other writers de- 
 nied the power of forming bone to various 
 parts of the body. Indeed the occurrence 
 of bony tumours, and the ossifications of 
 almost every organ in the body, so fre- 
 quently met wdth in the examinations of 
 morbid appearances, must have proved the 
 fact even to those who have been but little 
 conversant in the researches of practical 
 anatomy, I only contend that, in necrosis, 
 
 Q 
 
( 194 ) 
 
 the periosteum is the chief agent of repro- 
 duction; and if, in other affections, other 
 parts have also the power of depositing 
 bone, my position will not be at all inva- 
 lidated. 
 
 Mr. Russell's opinion, on the mode in 
 which the dead bone is removed, appears 
 to me particularly exceptionable, because 
 it leads us directly to form very erroneous 
 and dangerous conclusions concerning the 
 treatment of the complaint. I quote his 
 observations on this part of the subject from 
 the sixty- sixth and three following pages of 
 his Essay : 
 
 *^ In the other form of the attack, where 
 the sequestra is removed by dissolution and 
 absorption, without making its appearance 
 externally, the disease is more uniform in 
 its progress, and does not admit of so great 
 a variety of symptoms. The process is 
 necessarily tedious, and always attended 
 with a profuse discharge of matter. 
 
 •* The dissolution of the sequestra is more 
 
( 195 ) 
 
 or less complete. In young subjects it is 
 more quickly and more completely dis- 
 solved. In those of more mature age, the 
 dissolution of it is more tedious and un* 
 certain; and, in some cases, a small por- 
 tion remains unchanged, and resists all the 
 power of the system. 
 
 " The internal and softer parts disappear 
 first, and probably owe their decay to the 
 spontaneous decomposition which all parts 
 of the body naturally undergo, when they 
 are deprived of life, and detached from the 
 system. The gradual operation of these 
 unseen causes is, perhaps, sufficient to ac- 
 complish the destruction of the sequestra 
 in most cases. At the same time, their 
 action is doubtless very much promoted, 
 and the process of dissolution very greatly 
 accelerated, by the solvent power of the 
 purulent matter which surrounds the se- 
 questra ; for this constant maceration fa- 
 cilitates the spontaneous decomposition of 
 the detached bone, and by reducing it to a 
 fluid state, prepares it to be removed by 
 
 o 2 
 
( 196 ) 
 
 absorption, or to be washed out along with 
 the discharging of matter." 
 
 In answer to this statement, I contend, 
 in the first place, that we have no facts nor 
 experiments, which authorise us in ascrib- 
 ing to pus any such solyent power, as is 
 here represented. And, secondly, I affirm 
 that the appearances, exhibited by the se- 
 questra, are such as we should have ex- 
 pected, on the ground of its being absorbed 
 by the vascular lining of the new bone ; 
 and exactly the reverse of those, which the 
 immersion of the bone in a fluid capable of 
 dissolving it, would have exhibited. 
 
 The surface of the sequestra in contact 
 -with the granulations that line the new 
 osseous cylinder, is the part in which its 
 destruction proceeds the most vigorously. 
 Here the bone presents a kind of worm- 
 <^aten surface, with depressions and sharp 
 ridges corresponding to the form of the 
 granulations. And it is just in this part 
 that the close approximation of the new 
 and old bones leaves no roonj for the lodge* 
 
( 197 ) 
 
 ment of matter. In those situations, on the 
 contrary, where the sequestra is exposed in 
 the bottom of an ulcer, and where it must 
 be incessantly covered with pus, the process 
 of destruction stops. Had the removal of 
 the dead bone been effected by solution, 
 that cause should have shewn its operation 
 most unquestionably in this very part. Si- 
 milar phenomena may be noticed in exfo- 
 liation. Granulations make their way be- 
 tween the dead and living portions. They 
 first make a groove round the dead edge, 
 and then proceed, by the absorption of the 
 dead part in every direction, till they meet 
 in the centre. The inner surface of the 
 exfoliated piece presents the most unde- 
 niable proofs of the absorbent power of 
 the granulations ; while the exterior, which 
 has been all the time soaked in pus, is not 
 in the least altered. 
 
 After the immersion of a piece of bone in 
 a fluid capable of dissolving it, we should 
 naturally expect to trace the effect of the 
 menstruum by some alteration in the ap- 
 pearance of the surface subjected to its 
 
( 198 ) 
 
 Action. A softening of the bony substance 
 would be anticipated ; but no such change 
 is observed. The bone retains its natural 
 hardness, and possesses risings, &c. which 
 the action of a solvent would probably have 
 destroyed. 
 
 The pernicious practical consequence that 
 might be very fairly deduced from Mr. Rus- 
 sell's opinion, would be that of encoura- 
 ging suppuration, with the view of pro- 
 moting the solution of the sequestra. How 
 contrary such a doctrine is to the notions, 
 which ought to guide our treatment of 
 necrosis, will appear most clearly from the 
 observations which I shall presently make 
 on that part of the subject. 
 
 I. B. F. Leveille has, like M. Brun at 
 Toulouse, endeavoured to controvert the 
 opinion generally maintained, that a new 
 bony cylinder may be formed round the 
 original bone. The former writer on ne- 
 crosis observes: — '^ II ne faut pas croire 
 alors que I'os soit necrose dans toute son 
 epaisseur; car on se meprendroit beau- 
 
( 199 ) 
 
 eoup. II est frappe de mort dans cette 
 partie qui est plus voisine du canal, et 
 qui reccYoit particulierement la vie des 
 vaisseaux sanguins que lui transmettoit la 
 membrane meduUaire, son perioste interne. 
 Au contraire, tout ce qui est en rapport de 
 vitalite avec le perioste externe, ce qu'on 
 pourroit appeler avec Scarpa le cortex de 
 I'os, est parfaitement sain, et doit concou- 
 rir a I'expulsion du corps etranger qu'il 
 contient et qui lui est concentrique. Pour 
 cela, il se gonfle, se tumefie ; de compacte, 
 dense et serree qu'etoit sa texture, elle de- 
 vient epaisse, spongieuse, molle et moins 
 consistante. L'os pent acquerir un volume 
 considerable, et ofFrir une exostose des plus 
 prodigieuses. L'inflammation du tissu pa- 
 renchymateux de l'os sain, se continue 
 bientot au perioste, au tissu cellulaire qui le 
 recouvre, et a toutes les parties molles qui 
 I'avoisinent: en un mot, la totalite du mem- 
 bre est affectee. 
 
 *' Le pus augmente en quantite dans I'in- 
 terieur de l'os; chaque jour la pression 
 devient plus forte contre cette substance 
 
( 200 ) 
 
 spongieuse, molle, de I'exterieur de ce 
 meme os, autrefois d'une consistance si 
 dure et si serree. C'est cette partie nou- 
 vellement developpee, qui forme cette es- 
 pece d'etui, de gaine dans laquelle est con- 
 tenu le sequestre et le pus dont il est baigne 
 de toutes parts. Les parois de cette jiou- 
 velle cavite osseuse sont formees aux depens 
 de I'os lui meme, et non par un change- 
 ment d'etat du perioste."* 
 
 Mr. Macartney's observations are so 
 conclusive, that I should have no hesitation 
 in adopting his opinions on the phenomena 
 which occur in necrosis, even if I had not 
 had ocular proof that the sequestra in the 
 early stages of the complaint preserves the 
 bulk and figure of the original bone, which 
 never could have happened unless that part 
 had perished in its whole substance. Of 
 this fact I have been still more completely 
 satisfied by viewing different specimens pre- 
 served in Mr. Abernethy's Museum, in the 
 presence of Mr. Lawrence, the anatomical 
 demonstrator. 
 
 * Memoires de Physiologic et de Ghirurgie pratique^ par 
 Scurpa et Leveille_^ p. 283, 285. 
 
( 201 ) 
 
 The soft parts investing a bone which is 
 undergoing necrosis, suffer in the same 
 manner as we have described in white- 
 swelUngs : they inflame and suppurate, and 
 at this period the patient is brought into a 
 very alarming and hazardous situation. To 
 reheve this complaint, an operation has been 
 proposed, that of denuding the new osseous 
 shell, and perforating it with a view to 
 extract the sequestra. In some cases, in 
 which the bone has become dead to a small 
 extent^ and is thinly covered, such an at- 
 tempt may be feasible ; but in the majority 
 of instances, and especially in the thigh 
 bone, it must be utterly impracticable. — 
 Amputation might certainly be performed 
 in these cases, but not without the proba- 
 bility of extensive exfoliation. I can re- 
 commend a mode of treatment which su- 
 persedes the necessity of either of these 
 formidable operations, which indeed is ex- 
 actly similar to that adopted for the relief 
 of soft parts covering a diseased joint. 
 
 The occasional application of leeches, 
 combined with the use of blisters, and the 
 
( 202 ) 
 
 savine cerate, will obviate the occurrence 
 of abscess ; a most important point in the 
 treatment of the complaint. If the exter- 
 nal parts are kept free from disease, by 
 these means, the absorption of the seques- 
 tra will in process of time be effected. The 
 extent to which these remedies must be 
 employed, and the frequency of their repe- 
 tition must depend upon the irritation ex- 
 cited in the external parts. If there is an 
 interval of ease, and the limb is neither 
 swollen nor tender to the touch, the treat- 
 ment may be interrupted for a time; but 
 whenever pain is again felt, the use of 
 leeches must be immediately resorted to ; 
 and when ease has been procured by their 
 application, blisters and the savine cerate 
 must be again employed. The first case I 
 ever treated in this manner, I mistook for a 
 disease of the thigh bone. The patient 
 became so well as to quit St. Clement's 
 Workhouse, to which she returned after an 
 absence of above six months, in a hectic 
 and miserably reduced condition, having 
 just quitted a hospital, in which she had 
 been salivated. Although I succeeded ia 
 
( 203 ) 
 
 preventing the formation of abscess, she 
 died in three weeks, and afforded me an 
 opportunity of examining the disease, which 
 I found to be necrosis, and not, as 1 first 
 imagined, a carious bone. I have been 
 equally successful, and less ignorant of the 
 nature of the case in other instances; but I 
 will not claim the merit of being the ori- 
 ginal proposer of this mode of treatment; 
 for when I communicated my notions on 
 the subject to Mr. Abernethy, I found 
 that he had already in his lectures pro- 
 mulgated this doctrine; to him therefore 
 mankind is more largely indebted for the 
 usefulness and propriety of this mode of 
 treatment, than may have been hitherto 
 conceived. I only know, that we think 
 alike on the subject of cure, and shall leave 
 to his much more able pen the publication 
 of his own remarks. 
 
( 204 ) 
 
 SECTION X. 
 
 On Lumbar Abscess. 
 
 KEMEDIES, recommended in particular 
 complaints, have frequently, in consequence 
 of too general an application, lost their re- 
 putation for the cure even of those diseases, 
 for which they were originally intended. 
 Hence, I should be sorry to have it supposed, 
 that I either adopt in my own practice, or 
 recommend to others, the indiscriminate 
 use of any particular mode of treatment ; 
 and 1 trust, that the relation, which the 
 cases hereafter mentioned bear to the more 
 immediate subject of my observations, will 
 avert the possibility of such an imputation. 
 
 The effect, which I had observed artificial 
 drains to produce, in discussing several col- 
 lections of fluids, and even in dispersing the 
 abscesses, which generally attend white- 
 
( 205 ) 
 
 swelling, naturally led me to employ the 
 same treatment in similar complaints of 
 other parts of the body. The first oppor- 
 tunity, that I met with, of bringing my 
 opinion on this subject to the test of prac- 
 tice, was a case of large lumbar abscess. 
 
 The patient, who was of a strumous 
 habit, had, in the early part of his life, 
 laboured under a diseased hip, which re- 
 covered, after passing through the suppu- 
 rative stage. The skin, covering the most 
 prominent part of the abscess, for which he 
 applied to me, was thin and inflamed. He 
 was very weak and feverish, and was trou- 
 bled with night-sweats, flushings, loss of 
 appetite, and cough. 
 
 I feared, that if the abscess burst, or was 
 opened, while the patient remained in this 
 state, he would sink under the discharge, 
 and therefore applied a blister over the 
 whole swelling. After removing the cu- 
 ticle, the part was dressed regularly every 
 day, with the ceratum sabinae, and the dis- 
 charge which took place was so far from 
 
( 206 ) 
 
 producing any debilitating efFect, that the 
 patient's health was gradually restored: the 
 pain in the part slowly abated, and, in a 
 short time, the size of the tumour was very 
 perceptibly reduced. 
 
 By submitting to this treatment, for 
 nearly the space of a year, he completely 
 recovered, and has since enjoyed a perfect 
 state of health. That part of the swelling, 
 where the skin was thin and inflamed, at 
 last ulcerated ; but no matter escaped, nor 
 did the introduction of a probe into the sore 
 lead to any cavity. 
 
 Another case of lumbar abscess was suc- 
 cessfully treated in the same way. The 
 size of the tumour in the loin, was so large, 
 that it could not be included within a pint 
 bason ; and there was another swelling 
 below Paupart's ligament of smaller dimen- 
 sions. That the purulent fluid was con- 
 tained in one sac, appeared clearly, from 
 the impetus caused by striking the superior 
 tumor, being transmitted to the hand placed 
 on the inferior one. I applied a blister on 
 
( 207 ) 
 
 the lumbar abscess, and dressed the part 
 with the ceratum sabinae. A gradual dimi- 
 nution, and at last an entire removal of the 
 swelling below Paupart's ligament took 
 place, but no reduction of the tumour in 
 the loin had then succeeded: at length,- 
 however, this also entirely disappeared. 
 The manner in which the swellings were 
 successively removed, afforded an addi- 
 tional proof of the discussing effect of the 
 means I used. 
 
 A woman applied to me on account of a 
 very large lumbar abscess. This I immedi- 
 ately punctured with a small trocar, when 
 twelve ounces of inodorous matter of good 
 consistence were discharged. I tapped the 
 swelling about twenty times at intervals of 
 six or seven days, and the cyst became so 
 contracted in consequence of these repeated 
 operations, that an ounce of matter only 
 escaped from the last puncture. Having 
 found that the surface of the abscess was 
 now no greater than might be expected to 
 furnish such a quantity^ I enlarged the 
 
( 208 ) 
 
 opening, and the wound, from whieh some 
 flakes escaped, healed in a fortnight. One 
 circumstance which occurred in the early 
 part of my attendance on this case deserves 
 to be mentioned. 
 
 The sac became painfully distended, while 
 I was absent from town a few days, and 
 the fluid discharged from the next punc- 
 ture was extremely offensive. I now tap- 
 ped the tumor every other day for a week, 
 when the matter lost its smell, and re- 
 gained its usual appearance. I conceive 
 that the unfavorable change in the pro- 
 perties of the matter, can only be ac- 
 counted for by the inflammation excited 
 by the distension of the cyst. 
 
 The termination of another case was 
 equally successful ; but the patient died 
 two years after her cure of phthisis pul- 
 monalis. When the trocar is employed 
 for the evacuation of a lumbar abscess, any 
 flake of cellular membrane, or coagulable 
 Jymph, that impedes the flow of matter. 
 
( 209 ) 
 
 can be easily pressed back by the introduc- 
 tion of a probe through the canula. In the 
 cases above-mentioned, I always introduced 
 the trocar through the same puncture, and 
 was pleased in observing that the aperture 
 did not ulcerate, and that no matter escaped 
 after the part was dressed. I have had no 
 opportunity of examining persons who died 
 with these complaints. 
 
 I have never observed a single patient 
 with lumbar abscess paralysed in the lower 
 limbs : but I should expect that if the dis- 
 ease originated in a morbid state of the 
 bodies of the vertebrse, symptoms of palsy 
 must necessarily precede the appearance of 
 the abscess. If such a case should occur to 
 my notice, I certainly would attempt the 
 dispersion of the abscess by means of a pu- 
 rulent drain. 
 
 About fourteen years ago I was sent for 
 to Lambeth, to see a person who had lost 
 the use of her upper extremities for some 
 months. I begged to examine the state of 
 her neck, and discovered an abscess which 
 
( 210 ) 
 
 originated from a carious state of the cervi- 
 cal vertebrae ; I directed a blister to be ap- 
 plied over this, and that after the cuticle 
 was removed the surface should be dressed 
 with the cantharid ointment ; for at that 
 time I had not discovered the efficacy of 
 the savine cerate, and the integuments were 
 too inflamed and thin to admit of the caus- 
 tic. 
 
 A singular appearance manifested itself 
 on removing the cloaths to view this ab- 
 scess. One side of the chest was covered 
 to a great extent with a layer of incrusted 
 matter. She informed me that her breast 
 and the surrounding parts had been de- 
 stroyed by cancer, and that, if this incrus- 
 tation was by any means partially detached, 
 the sore spread until it was reproduced. It is 
 right to mention that my opinion was asked 
 not on account of the palsied state of the 
 upper extremities, but to relieve her fronv 
 the painful condition of the abscess. 
 
 The practice of discharging large collec- 
 tions of fluid in gradual quantities by the 
 
( 211 ) 
 
 means of a trocar is by no means novel. 
 We find that Deckers* adopted this plan 
 in the case of a very large tumor which 
 was situated on the internal surface of the 
 thigh, but it seems the canula was not 
 removed, and that a cork was put into it 
 to regulate the precise quantity, which was 
 to be discharged at different times 
 
 I was surprised to find Mr. Benja.min 
 Bell recommending the same practice in 
 cases of lumbar abscess. This systematic 
 writer observes : " The matter, however, 
 ought certainly to be discharged in such a 
 way as to prevent the air as effectually as 
 possible from getting access to the cavity 
 of the abscess. With this view a trocar 
 may be used with advantage. By pressing 
 the matter down to the most depending 
 part of the abscess, the skin is made so 
 tense, that a trocar is easily introduced. 
 This I have done in different cases with 
 complete success : and the patients wore a 
 small canula in the opening for several 
 
 * Deckers exercitationes practicae circa raedendi metho- 
 dum, 1696. 
 
 P 2 
 
( 212 ) 
 
 months, for the purpose of giving a free 
 vent to the matter." I am not at all ama- 
 zed, from the continued source of irritation, 
 which the retention of the canula must have 
 produced, that such a length of time was 
 required for the recovery of the patients, 
 and. I consider them as extremely lucky to 
 have escaped the usual fatal consequences 
 of such long- continued draining. 
 
 The advantage of treatment which I have 
 employed for the relief of lumbar abscess, 
 appeared to me to have been derived from 
 puncturing the cyst at different times, by 
 which means an immense cavity is enabled 
 to contract itself to the smallest possible 
 dimensions. The part was punctured with 
 a small hydrocele trocar, and care was taken 
 that the aperture should heal by the first 
 dressing. 1 have tapped these collections 
 frequently in the same part, in some cases 
 above thirty times, and the puncture has 
 always closed immediately. A piece of 
 lint and adhesive plaister were the only 
 dressings I employed. 
 
( 213 ) 
 
 ' Mr. Aberj^ethy, as appears in his first 
 essay on lumbar abscess, was not accus- 
 tomed to discharge the whole contents of 
 the cyst at one time, but in his supple- 
 ment on this subject, we find this very res- 
 pectable surgeon, expressing himself thus : 
 *' When I first began to open lumbar ab- 
 scesses in the method I have recommended 
 in this and my former essay on the subject, 
 I was extremely solicitous to do it in such 
 a manner, that the inner part of the aper- 
 ture might act as a valve, to prevent any 
 matter from oozing out so as to keep the 
 orifice open. I have found, however, that 
 great care in this respect was quite unneces- 
 sary, and by using a broad abscess lancet, 
 the wound is generally sufficient to give a 
 discharge to those coagula which are fre- 
 quently found in the matter. I always 
 completely empty the abscess, and then 
 bring the lips of the orifice together by 
 means of lint and sticking plaister, as after 
 the operation of phlebotomy ; and over these 
 a compress and bandage are applied. I dress 
 the wounds every second day, and of late 
 •have found very little difficulty in heahng 
 
( 214 ) 
 
 them, though many of them granulate 
 before they completely unite. The only 
 troublesome circumstance that has lately 
 occurred to me, has been an enlargement 
 of the lymphatic glands on the part of the 
 thigh, at the place where the abscess has 
 been opened." 
 
 I have seen my father let out the matter 
 by a small puncture with a bleeding lancet, 
 as he made no attempt to heal the orifice^ 
 it remained open, and this want of precau- 
 tion may account for the fatal termination 
 w^hich constantly ensued. This ill success 
 determined me, in the earlier part of my 
 practice, to leave lumbar abscesses to 
 burst of themselves. The evacuation of 
 the whole matter at one time, produced a 
 very weakening effect, which the patient 
 never got the better of; whereas, when 
 the pus escaped gradually, some cases did 
 recover. I presume to recommend the 
 practitioner to exert every means for the 
 immediate healing of the wound; for if 
 that should not take place, the patient* " 
 will be in no better situation than those ' 
 
( 215 ) 
 
 who submitted themselves to my father's 
 care. 
 
 I have read Mr. Abernetht's two tracts 
 on lumbar abscess with considerable inte- 
 rest, but cannot avoid wishing that my 
 friend had been more generally successful 
 in procuring the immediate healing of the 
 wound ; I think if he had thus been fortu- 
 nate he might not have experienced the 
 trouble he complained of with respect to 
 the lymphatic glands of the thigh ; nor pro- 
 bably should I have had the opportunity 
 afforded me of dissenting in the slightest 
 particular from the practice adopted by him 
 in instances of lumbar abscess. 
 
( 216 ) 
 
 SECTION XL 
 
 ON THE CURVATURE OF THE SPINE. 
 
 1 HE history and treatment of that species 
 of curved spine, Avhich is attended with pa- 
 ralysis of the lower extremities, have been 
 so ably described by our immortal country- 
 man. Pott, that nothing remains for any 
 future writer on the subject, but to give his 
 sanction to the means which he so fortu- 
 nately suggested for the relief of the com- 
 plaint. To this course I should most cer- 
 tainly have confined myself, had not a pub- 
 lication appeared lately, containing what 
 seems to me to be the most erroneous 
 notions on the nature and treatment of 
 the disease. It must be very clear that I 
 can experience no gratification in engaging 
 in a controversy with Sir James Earle ; 
 and I add the present section to my work, 
 because I consider it incumbent on every 
 
( 217 ) 
 
 writer to notice the errors of his predeces- 
 sors, without any personal or unpleasant 
 allusion to their authors. 
 
 A practical surgeon would not discharge 
 his duty to the public, nor shew a proper 
 respect for the character of his profession, 
 unless he exerted himself in the removal 
 of mistaken impressions, without regarding 
 their author, or the circumstances under 
 which they were produced : nay more, if 
 he neglected to point out errors in his own 
 writings, or in the works of others, I 
 should consider him as actually respon- 
 sible for their consequences. These mo- 
 tives operate the more powerfully on my 
 mind, on the present occasion, inasmuch 
 as the gentleman above-mentioned, the 
 author of the pamphlet alluded to, is a 
 near relation of Mr. Pott's, and holds the 
 situation of senior surgeon to the largest 
 hospital in this metropolis. The objec- 
 tionable statements of Sir J. Earle may be 
 reduced to the two following propositions. 
 First, that nature has the power of supply- 
 ing the place of the vertebra, destroyed by 
 
( 218 ) 
 
 the disease, by means of a newly-formed 
 substance ; and, secondly, that the proper 
 mode of treatment consists in the use of 
 such machines, as by supporting the weight 
 of the upper parts of the body, may pre- 
 vent the approximation of the vertebrae si- 
 tuated immediately above and below the 
 chasm created by the disease ; or may even 
 allow an opportunity for the spine already 
 curved to regain its natural figure. The 
 following quotations will shew that I have 
 not misrepresented his opinions on these 
 subjects. 
 
 *' The first and great object in our en- 
 deavour to relieve this disease, must be to 
 prevent the increase or continuance of the 
 caries, and to give nature an opportunity of 
 restoring the weakened part by furnishing 
 fresh growth of bony matter." 
 
 " Surely it appears reasonable that those 
 parts should be strengthened and supported, 
 while nature with the assistance of issues is 
 doing the work of restoration by putting a 
 stop to the caries, after which bony matter 
 
( 219 ) 
 
 is deposited to supply the deficiency which 
 the disease has produced. We apply sphnts 
 to a broken leg, while ossification is form- 
 ing, we do not 'allow any pressure to be 
 made on it, while that natural process is 
 going on, and the patient takes ofF the 
 weight of the body from it by means of 
 crutches, until it is perfectly strong, and 
 capable of its own duty. I am at a loss to 
 find any good reason, or sound argument, 
 why the same means of assistance, at least 
 so far as it lies in our power, should not be 
 applied in cases of a weakened spine, in 
 order to take off superincumbent pressure, 
 and to endeavour to restore the actual form 
 of the spine during the progress of the 
 cure ; if this be not attempted or cannot be 
 brought about at this time, the consequence 
 must be that the back will remain crooked 
 during the cure. Nature is obliged to do 
 her work, while it is in the bent position, 
 and though the strength of the pillar be 
 subsequently encreased, the cure itself be- 
 comes in some degree an evil, and a lasting 
 one, as the growth of new bone in that si- 
 tuation must consolidate all the parts, and 
 
( 220 ) 
 
 must confirm the curvature, exactly, or 
 nearly as it stood, before the cure was at- 
 tempted; for whatever power the issues 
 have in strengthening, it cannot be sup- 
 posed that they can materially alter the 
 curve which is already formed. The pe- 
 riod when we are most likely to improve 
 the form of the pillar must be during the 
 progress of the cure, while the parts allow 
 of some latitude of motion ; when they are 
 once become consoUdated and fixed by 
 the growth of bony matter, no alteration 
 scarcely can take place but what is effected 
 by the future general growth of the whole 
 body/* 
 
 I shall have great satisfaction, if I am so 
 fortunate as to convince Sir James Earle 
 of his error, and to effect this desirable 
 object, I shall insist in the first place, that 
 no specimen of diseased vertebrae is to be 
 found exhibiting such a deposition of new 
 bony matter, as this author describes. If 
 previously to the espousal of his hypothe- 
 tical notions. Sir J. Earle had glanced his 
 eye over the engraved plates, which Mr. 
 
( 221 ) 
 
 Pott's publication on this subject contains, 
 or had taken the trouble of inspecting some 
 specimens in Mr. Abernethy's museum, he 
 would have been satisfied of the truth of 
 this assertion. In short it appears, that in 
 every case there is no more ossific matter 
 supplied than is requisite to cement the 
 bones together. Indeed if the circum- 
 stance had been otherwise, we should pro- 
 bably have had occasion rather to deplore 
 the miserable condition of the patient, than 
 to admire the all-wise disposition of the 
 creator. For if bony matter had been so 
 profusely secreted as to supply the hiatus 
 caused by the destruction of the bodies of 
 two, three, or four vertebrcE, which occur 
 not unfrequently in this complaint, endless 
 sufferings of the paralytic kind would pro- 
 bably have ensued from the newly- depo- 
 sited bone pressing on the spinal marrow, 
 laid bare to so great an extent. If then it 
 be granted, as the inspection of every spe- 
 cimen in this department of morbid ana- 
 tomy most incontrovertibly proves, that 
 the chasm caused by the loss of the bodies 
 of the vertebrae is never filled up by any 
 
( 222 ) 
 
 |iew matter, the reader will anticipate the 
 conclusion to which I am hastening; viz. 
 that when the disease has proceeded so far 
 as to destroy one or more bones, the cur- 
 vature caused by the approximation of the 
 neighbouring sound ones, is a necessary 
 part of the curative process ; that the pa- 
 tient could not recover unless this salutary 
 curve took place, and consequently that 
 " the preservation of the upright figure of 
 the human frame," is an object incompa- 
 tible with the restoration of the patient's 
 health. The annexed engraving will suf- 
 ficiently explain and illustrate the view 
 which I have taken of this subject. I 
 may adduce the words of Mr. Pott in 
 order to confirm my opinion that the curve 
 is the effect of the disease, and that the 
 paralytic symptoms cannot quit the pa- 
 tient, until the chasm occasioned by the 
 loss of the bodies of the vertebrae has been 
 removed by the approximation of the bones 
 above and below the complaint. 
 
 This author observes that " there is no 
 displacement of the vertebrse with regard 
 
( 223 ) 
 
 to each other, and that the spine bends for- 
 ward only because the rotten bone or bones 
 being unable in such a state to bear the 
 weight of the parts above ^" and in another 
 part he remarks, " that according to the 
 degree of carious erosion, and according to 
 the number of the vertebrae affected, the 
 curve must be less or greater." Having 
 thus proved, as I trust, to the reader's sa- 
 tisfaction, that Sir James Earle's first posi- 
 tion is totally unfounded, the treatment 
 which he has founded on this, must neces- 
 sarily fall to the ground, and I might there- 
 fore be justified in passing over his obser- 
 vations on that part of the subject in. 
 entire silence. I shall, however, take the 
 liberty of making a few additional remarks. 
 Any effort used to prevent the approxima- 
 tion of the bones, if such an object could 
 be effected, would be injurious, I will pay 
 a compliment to Sir James's theory, and 
 suppose he is able to amend the crooked 
 figure of the spine by his machine ; will he 
 then undertake that ossific matter shall be 
 secreted in the quantity necessary to oc- 
 cupy the place occasioned by the loss of 
 
( 224 ) 
 
 the bodies of the vertebrae ? He has pro- 
 mised as much, but I am confident he will 
 never keep his word, and we ought to be 
 grateful that he will never have it in his 
 power. I will not offend the reader's 
 judgement by describing the efficacy of 
 instruments in the various cases, to which 
 their application has proved serviceable, es- 
 pecially as these occurrences are in no way 
 connected with the subject under present 
 consideration. We know well how to ap- 
 preciate the value of mechanical assistance 
 in deformities which arise from weakness, 
 or in such as are naturally produced, but 
 my experience has most clearly taught me 
 that such assistance is not in the least 
 degree availing in that curvature of the 
 spine, which is occasioned by the loss of 
 one or more of the bodies of the vertebrae. 
 On this subject therefore I may venture to 
 state, that the result of practice will con- 
 firm the reasonings already adduced con- 
 cerning the natural processes which accom- 
 plish the cure of this complaint. I should 
 be wanting in candour, if I did not inform 
 ,the student, that I employed the instru- 
 
( 225 ) 
 
 ment recommended bj Sir James, in a case 
 of curvature of the spine, attended with 
 paralysis of the lower limbs. The machine 
 was worn one day, but the child, who was 
 about six years of age, could not be pre- 
 vailed upon to submit to a second applica- 
 tion : it was not unaptly remarked at the 
 time, that if the child were to carry the 
 instrument, there should be some contri- 
 vance invented to carry the child. The 
 other instance in w^hich the mechanism 
 failed, was in a case which Sir James Earle 
 attended ; the persisted recommendation of 
 the use of the instrument first introduced 
 me to the notice of the family. This case 
 recovered by Mr. Pott's treatment, unaid- 
 ed by any mechanical means. In the in- 
 stances I have mentioned, its failure, or 
 rather its inutility, appeared at the com- 
 mencement of the treatment, and that was 
 the period in which it would have been 
 more fairly ascertained what relief mecha- 
 nical aid. was likely to afford. 
 
 I take shame to myself, that I could have 
 been guilty of such weakness, as ever to 
 
 Q 
 
( 226 ) 
 
 have recommended the instrument; and 
 the only amends I can make is the assu- 
 rance, that I will never in future adopt 
 any mode of treatment, without having first 
 fairly and fully investigated its merits. I 
 refer the reader to the four cases which Sir 
 James Earle has brought forward, as proofs 
 of the efficacy of mechanical assistance ; and 
 am inclined to believe, that he will concur 
 with me in opinion, that they go fully to 
 establish the advantages caustics were of, 
 without shewing that any benefit was de- 
 rived from the use of the machine. 
 
 There is another point of practice recom- 
 mended by Sir James Earle, to which I 
 cannot readily assent ; and that is a prefer- 
 ence given by him to the seton. This sub- 
 ject is introduced by the insertion of a let- 
 ter written by Dr. Latham, in which he 
 says " it is not merely an issue that is 
 wanted, but a deep-seated drain ; and the 
 nearer to the caries such drain can be esta- 
 blished, the better chance there must be for 
 the removal of the disease. " The setons," 
 Dr. L. goes on to say, " have indeed a ma- 
 
( 227 ) 
 
 nifest advantage over common issues, for 
 they embrace a larger extent." The situation 
 for either of these remedies is the same : if 
 the caustic be employed, the integuments 
 are destroyed ; if the seton be used, the skein 
 of silk is lodged under them ; and it is the 
 same surface which supplies the purulent 
 discharge in both instances. I always 
 thought that the suppuration was propor- 
 tioned in its degree to the destruction of 
 parts. A train of caustic can be applied in 
 any situation of the spine, and to any ex- 
 tent, which is not the case with the seton. 
 In curved spines the integuments cannot 
 be thrown into folds for the use of the se- 
 ton-needle, but this circumstance affords no 
 obstacle to the application of the caustic. 
 
 That Dr. Latham directed a seton to be 
 inserted, so as to include the extraordinary 
 space of about six inches, I verily believe ; 
 but I must hesitate a little in believing that 
 the operation was eifected as he prescribed. 
 I have the highest opinion of Dr. L.'s me- 
 dical abilities, but I hope he will excuse me 
 
 Q 2 
 
( 228 ) 
 
 for thinking, that in the surgical depart- 
 ment he may be considered rather too theo- 
 retical. 
 
 To Sir James Earle's assertion, " that it 
 (Dr. L.'s letter) certainly strongly corrobo- 
 rates the advantages to be derived from se- 
 tons, and shev^s how well calculated they 
 are to search out the situation of the dis- 
 ease, when it is not perfectly apparent to 
 the sight or touch," I think it unnecessary 
 to reply ; as it is very evident, that the 
 judgment of the practitioner must discover 
 the proper situation for the remedy, and 
 be most likely to detect the seat of disease. 
 
 I strongly recommend the young practi- 
 tioner to prefer the caustic issue to a seton : 
 the former remedy can be employed to 
 any extent, whereas the latter, in cases of 
 considerable curvature, cannot be so applied 
 as to include the whole seat of the com- 
 plaint within its operation. 
 
 I cannot take leave of Sir James Eakle 
 without stating, that I think the community 
 
( 229 ) 
 
 indebted in a very great degree to him, for 
 the more general introduction of injection, 
 as a radical cure for hydrocele ; and so zea- 
 lous am I for the improvement of our pro- 
 fession, that I experience much regret that 
 I cannot with equal propriety felicitate this 
 author dn any of his other attempts to ad- 
 vance the art of surgery. 
 
 It ought to be noticed, that, in the his- 
 tory of the case communicated by Dr. 
 Latham, in the letter addressed to Sir 
 James Earle there could have been no 
 curvature : the Doctor says, " In a case 
 about two years ago, where the effects 
 of pressure of the spine were but too evi- 
 dent, from a total loss of sensation in the 
 lower extremities, and where, from the same 
 cause, there were involuntary discharges of 
 urine, and very obstinate costiveness, and, 
 in short, every symptom which usually cha- 
 racterizes the disease ; but where the pre- 
 cise spot of pressure could not exactly be 
 ascertained, I directed a seton to be inserted 
 on each side of the spine, so as to include a 
 space of about six inches. In a very few 
 
( 230 ) 
 
 days some advantages were observable ; and 
 in three weeks he had a greater command 
 over his urine than he had experienced for 
 many months. The setons were main- 
 tained for more than half a year, without 
 any other difficulty than the insertion of a 
 clean skein of silk when the old one was 
 nearly expended, and which was easily ef- 
 fected, by looping that which was fresh 
 into the end of the other ; about which time 
 the patient was so far recovered, as to walk 
 with the assistance of a stick." This is cer- 
 tainly a good case, and the Doctor mani- 
 fested much professional judgment in the 
 treatment of it ; but had there been curva- 
 ture the integuments would have been more 
 on the stretch, and the person who passed 
 the seton would not have had it in his power 
 to have occupied such a quantity of parts as 
 intimated in this letter. 
 
 Mr. Benjamin Bell does not speak with 
 confidence of the good effect of issues in 
 curvatures of the spine, attended with ca- 
 ries ; nor, indeed, does he seem to entertain 
 notions similar to those which Mr. Pott 
 
( 231 ) 
 
 formed, and which others entertain on the 
 subject. He says, *' Mr. Pott, to whose 
 observations upon this subject we are much 
 indebted, speaks highly of the effects of 
 issues placed as near as possible to the tu- 
 mour. He advised an issue to be opened 
 with caustic on each side of the tumour, 
 large enough to admit of a kidney-bean, and 
 the bottom of the sore to be sprinkled, from 
 time to time, with the powder of canthari- 
 des. This I have often practised, in various 
 cases ; and in some instances with good ef- 
 fects. But in all of these there was reason 
 to suppose, that the seat of the disease was 
 in the ligaments only, and not in the bones 
 of the spine. When they have appeared to 
 prove useful, the bones have been not af- 
 fected. I conclude that the mitigation of 
 symptoms has arisen from the cause I have 
 mentioned, the pressure upon the spinal 
 marrow being lessened in the progress of 
 the disease."* 
 
 * Surely the author should have substituted the word 
 '' cure'' for " disease." 
 
( 232 ) 
 
 The issues should be of sufficient length 
 to extend above and below the curve pro- 
 duced by the diseased state of the spine. 
 Mr. Pott in his practice certainly caused 
 his eschars to be made of a size consi- 
 derably more extensive than his publica- 
 tion directs. When we speak of curve, 
 we are not to imply that state of bend 
 which must necessarily arise from the whole 
 spine above the complaint falling forwards, 
 but that projection of the spinous processes 
 marking the degree of curvature. Mr. Pott 
 insisted in his lectures, and very justly, that 
 there could be no curvature of the spine, of 
 the nature he had written upon, without 
 the body or bodies of the vertebrae giving 
 way, in consequence of disease : whereas 
 Mr. Bell speaks of curvature arising from 
 a morbid state of the ligaments. It must 
 be apparent that this affection can bear no 
 analogy with the complaint which Mr. 
 Pott described in his Tracts on Curved 
 Spine. Another fact, of no small impor- 
 tance, is, that the bodies of the vertebrae 
 must be more or less destroyed, to produce 
 a curvature from within outwards. A weak- 
 
( 233 ) 
 
 ness, or disease of the ligaments, rather 
 tend to the production of a lateral curve ; 
 although I know that sometimes the spine 
 is bent forwards ; but if the patient be re- 
 lieved of the weight of the upper part du- 
 ring the surgeon's examination of the com- 
 plaint, it will be readilj seen what degree 
 of deformity is attributable to weakness, 
 and what may properly be ascribed to ca- 
 ries; above and below which the caustic 
 remedy ought to be applied. 
 
( 234 ) 
 
 SECTION XII. 
 
 ON SPINA BIFIDA. 
 
 J- HAVE been induced to add this section to 
 the preceding sheets, because the drawings 
 which were taken from the subjects afford a 
 satisfactory view of the state of parts attend- 
 ing Spina Bifida. — I have experienced the 
 want of such assistance, to satisfy the pa- 
 rents of the inutility of our art to remedy 
 this grievance. 
 
 The child from whom the bone was 
 taken had a swelling of the same appearance 
 as that which is described by Mr. Lang- 
 staff, and which he obligingly afforded me 
 an opportunity of seeing. In the case I at- 
 tended the tumour was distended with fluid, 
 which I discharged by a puncture : it was 
 pellucid, and incoagulable by acid or heat, 
 as recorded to be the property of the water 
 
( 235 ) 
 
 which is sometimes found in the brain of 
 maniacal subjects*. I was sorry that I eva- 
 cuated the sweUing, as the child's sufferings 
 seemed much increased. After the opera- 
 tion, it was seized with a tremulous motion 
 of its lower limbs, attended with inconti- 
 nence of urine and involuntary discharge 
 of the foeces ; and in three days after the 
 puncture was made the child died. 
 
 Mr. Benjamin Bell proposes to include 
 the base of the tumour in a ligature, and as 
 soon as the tumour has fallen off, to apply a 
 firm stuffed pad to the opening between the 
 vertebrcc. It must appear to every person 
 of the meanest capacity, what a condition 
 the child w^ould be in, if the parts did not 
 unite, which, from their texture, I think is 
 not improbable : they have appeared to me 
 as possessing vital powers very inadequate 
 to the expectation of any thing like a 
 healthy healing taking place. In the case I 
 punctured, the opening manifested no dis- 
 position to heal, and fluid constantly flowed 
 from it until the child died. 
 
 * Haslam's Observations ou Insanity. 
 
( 236 ) 
 
 I shall in future leave these cases to their 
 own fatal termination, as was the practice 
 of Mr. L. in his attendance on the follow- 
 ing case. 
 
 CASE. 
 
 '' An infant, two days old, was brought 
 to me, in August, I807, with a spina bifida, 
 situated in the lumbar vertebrce. The tu- 
 mour was about the size of a small pot 
 orange ; the integuments covering it were 
 of a beautiful transparent cherry colour, 
 except on the centre, which was ulcerated 
 to the circumference of a shilling. 
 
 *' The child, making every allowance for 
 its age, was small, deficient in strength and 
 vigour, and much emaciated ; and when the 
 tumour was gently pressed, great pain 
 seemed to be produced. 
 
 " The methods of cure hitherto recom- 
 mended having proved ineffectual ; and as 
 spina bifida is, I believe, allowed by the 
 
( 237 ) 
 
 most eminent practitioners to be incurable, 
 I did not think myself reprehensible by de- 
 termining to leave the event to nature. 
 
 ^'^ The child's bowels being disordered I 
 merely ordered an absorbent mixture'; and 
 requested it might not be placed on its back, 
 for fear of giving pain, and increasing the 
 ulcerative process. 
 
 " The tumour continue'd to increase gra- 
 dually, and the ulcerated part spread in pro- 
 portion, and secreted good pus till a few 
 days of its death, when the middle part be- 
 gan to protrude beyond the sound integu- 
 ments, and appeared quite diaphanous, and 
 a transparent fluid oozed from several mi- 
 nute points. 
 
 " The sufferings of the child were increas- 
 ed greatly about the time the fluid began to 
 make its escape through the protruding dura 
 mater ; the lowxr extremities were para- 
 lyzed, stool and urine voided without the 
 smallest effort of the child. 
 
( 238 ) 
 
 " The contents of the tumour oozed free- 
 ly from almost everj point of the ulcerated 
 surface, and in the course of that day were 
 nearly evacuated. I now applied a bandage, 
 but not with any hope of success : the suf- 
 ferings of the child were extreme, till the 
 time when death fortunately put an end to 
 its miserable ex:istence. 
 
 *' I obtained permission to open the body, 
 and removed as much of the spine, with 
 diseased integuments, as were necessary to 
 make a preparation; as I only wished to 
 shew the figure, situation, &c. of the tu- 
 mour, having other specimens of spina bi- 
 fida in my possession. 
 
 " The disease was unconnected with hy- 
 drocephalus internus. Bowels much de- 
 ranged in their functions ; sometimes con- 
 stipated ; at other times, diarrhoea so violent 
 as would, I have no doubt, had not means 
 been used to moderate it, have destroyed 
 the child." 
 
( 239 ) 
 
 SECTION XIII. 
 
 MISCELLANEOUS REMARKS. 
 
 N offering my opinion on several surgical 
 subjects, I disclaim any pretension to the 
 title of an Author. My object in intruding 
 my observations on the public attention 
 arises from a conviction in my mind, that 
 they have been confirmed by practice ; and 
 if acted upon by others, mankind might in 
 a degree be benefited. 
 
 Thus much is said for the remarks which 
 this section contains ; an apology equally re- 
 quired for the many other imperfections of 
 the same kind w^ith which the rest of the 
 work too generally abounds. 
 
 As a proof of the absorption of matter be- 
 ing no way injurious to the constitution, I 
 shall briefly state another circumstance un- 
 der which it occurred. 
 
( 240 ) 
 
 I was desired to visit a man, who after a 
 fever, which appeared, from the account 
 given of him, to have been typhus, was af- 
 flicted with a large abscess, occupying one 
 side of his face, and extending below the 
 jaw. It was painful to the touch, and the 
 skin w^as in one part reddened. After a dis- 
 charge had been kept up for three weeks, 
 the whole tumour dispersed, and the patient 
 got perfectly well. 
 
 After long continued fever, and sometimes 
 after the administration of mercury for a 
 length of time, patients complain of pain 
 within an articulation, which is followed by 
 an effusion within the joint. The applica- 
 tion of a few leeches to the part, and cold 
 acetous lotions, will procure ease ; and as 
 soon as that is obtained, the absorption of 
 the fluid has always succeeded the use of 
 blisters and the savin cerate, with appro- 
 priate bandage. Those affections of the 
 joints which succeed small pox, measles, 
 &c. in children, do not seem to require the 
 antiphlogistic treatment, but a drain may 
 be immediately resorted to. These mala? 
 
( 241 ) 
 
 dies very readily yield to this treatment ; 
 but it should be understood that this is an 
 effect by no means to be expected in other 
 cases of diseased joints, namely, those which 
 do not arise, as in these instances, from 
 temporary affections of the system. 
 
 Swellings of the glands have, by the treat- 
 ment of leeches and cold washes, been pre- 
 vented from suppurating, and I have seen 
 instances in which these tumors have con- 
 tinued in a painless and indolent state during 
 life, an effect every way preferable to their 
 forming abscess. I have been induced to 
 treat the integuments, covering a swollen 
 gland, with the view of preserving them 
 whole, in the same way as we have recom- 
 mended to be pursued with regard to the 
 external parts investing a diseased joint. 
 
 I have seen glands suppurated, but so 
 partially that I have endeavoured to keep 
 the integuments free from inflammation, 
 and passed electric shocks through the 
 gland, applying leeches to the skin and cold 
 washes. This practice has sometimes dis- 
 
 R 
 
( 242 ) 
 
 parsed these swellings ; at other times sup- 
 puration occurred, but under circumstances 
 more favorable, as the maturation was more 
 complete, and the skin was not diseased as 
 we too frequently find it. I have seen the 
 integuments inflame and ulcerate, while the 
 induration of the gland has been little di- 
 minished by the matter discharged. 
 
 A man has this moment applied for my 
 assistance: the integuments, covering the 
 enlarged gland, which had suppurated, were 
 partially inflamed and ulcerated. I think it 
 had been better if the skin had been kept 
 free from disease by the application of 
 leeches and cold washes. In those cases, 
 in which the gland has completely suppu- 
 rated, the matter should be discharged be- 
 fore the skin inflames, and the part will 
 readily heal by pressure and appropriate 
 dressing. 
 
 I have, after the application of leeches 
 and washes, dispersed swollen glands situ- 
 ated in the axilla and inguen, by directing 
 the patient to rub mercurial ointment in 
 
( 243 ) 
 
 the course of the absorbents. If this prac- 
 tice should be thought eligible the practi- 
 tioner should, to prevent misrepresentation, 
 assure the patient that he adopts this mode 
 of treatment with no impression of its being 
 venereal. 
 
 Strumous swellings of the inguinal glands, 
 of considerable size, have also yielded to 
 cicuta taken internally, and covering the 
 part with the emplastrum gummi ammo- 
 niaci cum hydrargyro. It was suggested 
 by a practitioner, that somewhat of the 
 advantage the patient received might be 
 attributed to the local treatment. In con- 
 sequence of this suggestion I contented 
 myself in other cases with giving the 
 hemlock alone, and had no reason, in the 
 recovery of the patient, to regret having 
 deprived him of any supposed benefit which 
 might have arisen from local treatment. 
 I was induced to try cicuta internally, 
 from having witnessed its effects in the 
 recovery of a patient who abounded with 
 scrofulous swellings in his limbs and dif- 
 ferent parts of his body. The person had 
 
 R 2 
 
( 244 ) 
 
 been under my care without receiving any 
 benefit ; he at length apphed to an eminent 
 physician, who directed the hemlock for 
 him. I mention this circumstance to shew 
 that I entertained no prejudged opinion of 
 the efficacy of hemlock in scrofulous cases. 
 
 In lax, debilitated, scrofulous persons the 
 nitrous acid taken internally in the propor- 
 tion of a drachm to a pint of water through 
 the day, has had the best effect in giving 
 strength, and restoring the health and ap- 
 petite of the patient. To children it is par- 
 ticularly palatable if sweetened with honey.i 
 I can in truth say, in those cases, it is an| 
 internal remedy greatly to be preferred tot 
 cinchona combined even with prepared na- 
 tron. 
 
 I have stated in the Introduction, that 
 the robust and the weak are subject to stru- 
 mous complaints, and that different treat- 
 ment in the cure of these maladies should 
 be adapted agreeably to the state of health 
 of the patient. 
 
( 245 ) 
 
 To a note left at Mr. Jeremiah Taylor's 
 house, requesting information respecting a 
 scrofulous patient of his, the following is 
 that gentleman's reply: — ** In answer to 
 your letter regarding the young lady whom 
 you incidentl}' saw at Kennington, I have 
 to observe, that, owing to the hint which I 
 received from you, I ordered her (she being 
 young and plethoric) to take purgative me- 
 dicines occasionally preceded by calomel at 
 night ; which treatment certainly prevented 
 suppuration from taking place on one side 
 of her neck, thereby preserving her from 
 the disfigurement which had obtained on 
 the other side, after a contrary mode of 
 treatment directed by another practitioner 
 a little time before I attended her." 
 
 I have seen two cases of hydro-sarcocele, 
 of the strumous kind, yield to electricity. 
 The one patient had, when a child, a swel- 
 ling of the knee, which recovered after the 
 suppurative stage of that complaint ; the 
 other had strumous swellings of the neck, 
 with scrofulous ophthalmy, at the time he 
 
( 246 ) 
 
 consulted me on account of the disease of 
 the testicle. 
 
 The two cases were so exactly similar, 
 the description of the one will answer to 
 that of the other. The body of the testis, | 
 and its epididymis formed one indistinct 
 mass, and the fluid collected in the tunica 
 vaginalis was sufficient in quantity to have 
 rendered its evacuation secure from harm ; 
 but feeling the posterior part of the swel- 
 ling the induration and enlargement of the 
 gland was very perceptible. It was smooth 
 in its surface, and not painful upon hand- 
 ling, the only particular uneasiness was its 
 weight which was taken off by wearing 
 a bag truss. I passed electric shocks 
 through the tumor daily for about tw^o 
 months, and the result of this treatment 
 was as follows: first, the absorption of the 
 fluid; secondly, the division of the swelling 
 into testis and epididymis; and lastly, the 
 reduction of these parts to their natural size 
 and healthy structure. I have in the true 
 carcinomatous testicle been directed to treat 
 it in the same way, a means in such a dis- 
 
( 247 ) 
 
 ease I will never again resort to, as it tended 
 to aggravate the painful symptoms and in- 
 crease the size of the swelling. 
 
 In a case of disease of the testis, which 
 from its symptoms I presumed to be an 
 abscess, I applied a small blister to the 
 scrotum, and maintained a discharge from 
 thence by the savin cerate. By this treat- 
 ment the fluid was dispersed, and the pa- 
 tient recovered with a diminished state of 
 the gland. 
 
 I have also dispersed by the application 
 of blisters, and dressing the part with the 
 savin cerate, several abscesses of the glands 
 of the neck, and three very large scrofulous 
 buboes, where the swellings were composed 
 of distinct glands, which were connected to 
 each other by intervening substances. 
 
 These last cases prove very tedious, and 
 the patient suffers much from the repeated 
 suppurations, which, in some instances suc- 
 ceed each other, for a space of more than 
 six months, and even then the part has 
 
( 248 ) 
 
 sometimes been left in a state of hardness ; 
 and when that happens, scrofulous ulcers 
 are very liable to break out again, and 
 fresh collections of matter to form. Ob- 
 serving that when this circumstance oc- 
 curred, the sores uniformly healed with 
 induration, I was induced to keep them 
 open, either by an occasional touch of the 
 lunar caustic, or a solution of it in water, 
 till all hardness was removed, and I think 
 I have also seen some effect from a mer- 
 curial dressing* in increasing the discharge, 
 and not only amending the state of the 
 sore, but causing the edges of the ulcers to 
 subside. 
 
 The opening of scrofulous abscesses in 
 
 * The precipitate by pure ammonia, from a solution of 
 mercury, in diluted nitrous acid, made in a low temperature, 
 and applied moist, the superabundant ammonia being pre- 
 viously washed away by distilled water. 
 
 The precipitate, after drying, has not appeared to me to 
 answer so well as whilst it retained its moisture, so as to 
 possess about the consistence of cream. It was first pro- 
 posed to me by Mr. Haslam, of Bethlem Hospital, as an 
 application to venereal sores, or any kind of ulcer, in which 
 the exter pal use of mercury might be thought adviseable, and 
 from my own experience I can recommend it in such cases. 
 
i 249 ) 
 
 general, when attended with circumscribed 
 hardness, has been found to be productive 
 of harm ; for these require, after artificial 
 opening, a longer time to recover than 
 when they are permitted to burst of them- 
 selves ; but an aperture is indispensibly 
 necessary in those collections of matter 
 which cannot be discussed, and are at- 
 tended with no surrounding hardness ; for 
 here, if the matter be not let out, it will 
 often diffuse itself into the cellular mem- 
 brane, and cause a number of extensive 
 sinuses. 
 
 After the bursting or laying open these 
 imposthumes, the sore has sometimes be- 
 come phagedenic, though indeed this term 
 will convey but an imperfect idea of that 
 state of sore I wish to describe. The true 
 phagedenic ulcer, according to my opinion 
 and observation, wears rather a cancerous 
 appearance, it enlarges rapidly, has inverted 
 edges, is irregular in its figure, and is some- 
 times attended with fungus; but the pa- 
 tient does not feel those lancinating pains, 
 nor does he complain of uneasiness when 
 
( 250 ) 
 
 the part is dressed, nor is the sore subject 
 to bleeding, as is the case in cancerous 
 ulcers ; indeed but for such distinctions, 
 and more particularly from these complaints 
 having recovered, they certainly might be 
 mistaken for cancerous. 
 
 I have seen six of these cases in the groin, 
 two of them vrere patients afflicted v^ith 
 the venereal disease, the others were scro- 
 fulous : mercury given in the first instance, 
 to those who were venereally affected, 
 tended to enlarge the sore, though it af- 
 terwards became necessary to complete the 
 cure. 
 
 In these complaints, lint dipped in tar, 
 had an excellent effect in checking the 
 farther progress of the sore, and disposing 
 it to suppurate kindly. And the application 
 of sorrel succeeded in two instances where 
 the tar and carrot poultices, with spirituous 
 fomentations, had failed. 
 
 I shall relate the cases of these sores, as 
 accurately as my recollection serves, be- 
 
( 251 ) 
 
 cause their appearances were peculiar and 
 striking. 
 
 A boy, about fifteen, had a large scrofu- 
 lous abscess in the fore part of his thigh, 
 which burst, and as the natural opening 
 was insufficient for letting out the matter, 
 I enlarged it with the probe-pointed his- 
 tory. Next morning, the whole sore had 
 become one continued slough, and was 
 without any surrounding hardness ; the mis- 
 chief went on rapidly spreading, notwith- 
 standing a very liberal use of the bark in- 
 ternally, and was not arrested till bruised 
 sorrel leaves were applied.* 
 
 A girl, about six years of age, was 
 brought to me on account of a scrofulous 
 
 * My idea of making this application was suggested by the 
 success stated by Dr. Beddoes to have followed the use of a 
 similar plant in some cases of scrofulous ulcerations. His tes- 
 timony is in favour of the ■wood-sorrel (Oxalis acetosella) 
 which I could not readily procure, and therefore substituted 
 for it the common wood-sorrel (Rumex acclosa) ; but it is 
 probable, from the larger relative proportion of oxalic acid 
 contained in the former plants that it may be superior in its 
 powers to the latter. 
 
( 252 ) 
 
 abscess seated on the ulna, which burst, 
 and produced a sore exactly of the descrip- 
 tion of the preceding one. The child suf- 
 fered much from the pain, and therefore a 
 solution of one grain of opium was given 
 daily, and as much bark as the stomach 
 could bear. Notwithstanding tar and other 
 applications were used, the sore continued 
 to spread, and I determined upon trying 
 the sorrel, intending, if this should fail in 
 checking the disposition to slough, to make 
 an escharotic application. This however 
 was unnecessary, for the sorrel soon gave a 
 healthy appearance to the sore which con- 
 tinued during its use ; and when it was af- 
 terwards dressed with lint and calamine 
 cerate, it degenerated into its former 
 sloughy state, which was again removed by 
 the application of the sorrel, and was at; 
 last totally healed by it. 
 
 Although a purulent drain, artificially 
 excited, ought not perhaps to be esteemed 
 a constitutional remedy, merely from an 
 improvement taking place in the patient's 
 health, in consequence of an amendment 
 
( 253 ) 
 
 occurring in a local disease; yet certainly it 
 establishes a claim to that appellation, when 
 we find other modifications of the same dis- 
 ease, existing at the same time, and in the 
 same patient, removed by a treatment 
 adopted only with a view to the relief of a 
 local complaint. Fact being at all times 
 preferable to theory, I shall relate some in- 
 stances inclining me to the opinion that an 
 artificial drain, in cases of scrofula, is in it- 
 self a constitutional remedy. 
 
 A young lady, about ten years old, had a 
 great number of scrofulous ulcers over her 
 body, besides the joints of most of her fin- 
 gers being enlarged. Her mother stated, 
 that the child had an aiFection of her chest, 
 with cough, difficulty of breathing, night- 
 sweats and flushings, and that as soon as 
 one sore healed, another broke out. I in- 
 formed her that as the child had tried what 
 medicine could do, I wished that she might 
 submit to an issue only. Accordingly I 
 made her one in the arm, and kept some of 
 the sores discharging by the ceratum sabi- 
 nae. In about two years after her first 
 
( 254 ) 
 
 application to me for relief, her mother in- 
 formed me, that she had completely reco- 
 vered of her complaints, excepting that 
 some of her fingers remained rather in a 
 contracted state. 
 
 The glands in the neck of a little boy, 
 of about three years old, were in a state of 
 suppuration, and his finger-joints conside- 
 rably enlarged. A tedious course of medi- 
 cine had afforded him no relief, and there- 
 fore I recommended an issue to be made in 
 the arm. After this discharge had been 
 kept up for three months, the enlargement 
 of the fingers entirely disappeared, and the 
 complaint in the neck was much amended. 
 
 From some of the cases which have been 
 stated, it will appear, that the general habit 
 of the patient has been improved by the 
 establishment of a drain, for the alleviation 
 of a diseased joint ; and that it may there- 
 fore be advantageously employed, as a con- 
 stitutional remedy. I have recorded some 
 instances, also, in which a relapse did oc- 
 cur after the sores were suffered to heal. 
 
( 255 ) 
 
 and the patient was obliged to submit to a 
 repetition of the same treatment. But 
 when an issue has been kept open in any 
 part of the body, for a considerable length 
 of time after the cure of the local disease, 
 no such accident has occurred. 
 
( 256 ) 
 
 SECTION XIY. 
 
 ON SCROFULOUS AFFECTIOXS OF THE HIP 
 JOINTS. 
 
 CONCEIVE that practitioners should have 
 in view, in the pubUcation of their writings, 
 either advancement of science, the statement 
 of new facts, or the correction of practical 
 errors, which have been received or circu- 
 lated through the medium of the press. 
 
 Medical authors, without a reference to 
 any one of these objects, may certainly ac- 
 quire by their writings literary fame ; but 
 they can never entitle themselves to the 
 esteem and good opinion of the profession. 
 Such writers and their productions will re- 
 ceive attention and respect from professional 
 rieaders, just in proportion as they tend to 
 advance the honor and usefulness of the 
 art, and thereby promote the advantage of 
 the public. 
 
( 257 ) 
 
 Impressed as I am with these sentiments, 
 I will never attempt to promulgate, as my 
 own, doctrines which have been before 
 maintained by others ; nor trespass on the 
 time of my reader, by stating the opinions 
 of other authors, which may be always 
 more clearly ascertained, and more fairly 
 appreciated, by a perusal of the original 
 works. 
 
 On hip affection, therefore, I have great 
 satisfaction in referring the reader to the 
 excellent observations of Mr. Ford, which 
 will furnish the requisite practical informa- 
 tion on this very important subject. By 
 thus pointing out a source of more copious 
 instruction, I conceive that I apologize 
 sufficiently for the small number and de- 
 sultory nature of my own observations. 
 
 Children are peculiarly subject to the dis- 
 ease called a scrofulous hip : and no case 
 has hitherto occurred to me, in which the 
 patient was not of a strumous habit. Af- 
 fections of this articulation, produced by 
 
( 258 ) 
 
 accident, may not all be of a scrofulous 
 nature; but the majority of such cases is 
 undoubtedly of that description. 
 
 The observations already made, concern- 
 ing the manner in which other articulations 
 are affected, apply with equal propriety to 
 the disease of the hip joint. The bones 
 become carious to a greater or less extent, 
 and all the soft parts belonging to the joint 
 are subsequently involved. In other cases 
 the ligaments are only affected ; or at least 
 they are first disordered, and seem to sus- 
 tain the the chief w^eight of the attack. 
 
 There are certain appearances in this 
 complaint dissimilar from those which at- 
 tend scrofulous affections of other joints. 
 The elongation and contraction of the limb 
 are the phenomena to which I now allude. 
 The peculiar position of the hip, and the 
 mode, in which the weight of the superior 
 parts of the body is sustained by this arti- 
 culation, seems to me to afford an adequate 
 solution of the former appearance; while 
 the latter owes its origin most undoubtedly 
 
( 259 ) 
 
 to the action of the muscles attached to the 
 thigh bone. 
 
 The earlj stage of this disease is very 
 generail}^ attended with an elongated con- 
 dition of the lower extremity of the affected 
 side ; a symptom, of which no surgical wri- 
 ter has hitherto assigned a satisfactory ex- 
 planation. The ancients, and indeed many 
 practitioners even of modern times, have 
 assigned as causes of the encreased length 
 of the Hmb, a supposed relaxation of the 
 orbicular ligament, or a distension of the 
 articular cavity by fluid effused into the 
 capsule. Such are the notions brought 
 forward by Galen and Fabricius to illus- 
 trate the meaning of the two aphorisms of 
 Hippocrates concerning the nature of this 
 disease.* 
 
 I insert these opinions, because, I con- 
 
 * Saepe in articulis humor pituitosus acervatnr, quem 
 myxam appellat (Hippocrates) a quo madefacta articulationis 
 ligamenta, laxiora redduntur : atque ideo facile a cavitate ar- 
 ticulus excidit, et rursus non cum difficultate incidit. — Galen 
 in Aphor. Hippocr. Com 6. 
 52 
 
( 260 ) 
 
 ceived until lately, that they afforded the 
 only rational means of accounting for the 
 lengthened condition of the limb. I rea- 
 soned from the laxity of the knee and 
 shoulder joint, which we frequently notice, 
 when those articulations become distended 
 by fluid effused into their cavity, and I con- 
 eluded that the symptom in question owed 
 its origin to an analogous state of the hip 
 joint. In referring to old authorities I have 
 at all times been influenced merely by their 
 usefulness. I have been irritated by ob- 
 iserving persons, under affectation of great 
 diffidence and modesty, apologizing for no- 
 ticing in their writings, the opinions of the 
 earlier authors. I verily believe, modern 
 surgery would have made much more rapid 
 advancement to perfection, had the labors 
 of the ancients been more generally ad- 
 verted to. 
 
 I shall quit this subject, by just remark- 
 In quo aphorismo Hippocrates causam assignatlaesiarticuli 
 femoris, quod excidat ef recidat, quam in pituitam rejicit 
 mucosam j et est ut puto ille, qui naturaliter solet contincri 
 in articulorum cavitate copia tamen plus aequo adanctus,— 
 Hieron. Fabricii Opera Chirurgica, c, 196, p. 643. 
 
( 261 ) 
 
 ing, that had a Hunter been acquainted 
 with the facts stated by ^xitrs and Wise- 
 man on the subject of aneurism, the labors 
 of an Abernethy would not have been re- 
 quired to perfect the surgical treatment 
 proposed by that late very eminent anato- 
 mist and practitioner. 
 
 The orbicular ligament of the hip is ex- 
 tremely dense and compact in its structure; 
 and in many parts not less than the tenth 
 of an inch in thickness. Instead of a loose 
 membranous bag, designed merely for se- 
 creting and containing the synovia, as in 
 most other joints, the capsule of the hip is 
 the ligament, by which the bones, compo- 
 sing this most important articulation, are 
 tied together with that degree of strength, 
 which the functions of the part so obviously 
 require ; hence, until the researches of the 
 anatomist, in the examinations of morbid 
 bodies shall have furnished some direct evi- 
 dence on the subject, we may reasonably 
 doubt whether such a part admit of the 
 same processes of distension and relaxation 
 which take place in joints of different or- 
 ganization. 
 
( 262 ) 
 
 A swollen state of the head of the thigh 
 bone, together with a thickening of the 
 acetabulum, have been assigned by some 
 writers as probable causes of the elonga- 
 tion. But I will not occupy my readers 
 time, by commenting on these hypothetical 
 notions, until the existence of the above- 
 mentioned appearances shall have been as- 
 certained by dissection. 
 
 There is only one more explanation 
 which I think it necessary to consider. 
 This refers the lengthening of the limb, to 
 the destruction of the articular cartilages, 
 and of the ligament completing the lower 
 and inner margin of the acetabulum. Ad- 
 mitting, for argument sake, what has not 
 yet been proved, that the changes just al- 
 luded to, do actually occur in every instance 
 of elongated limb, the gentlemen, who adopt 
 this notion, should have the goodness to in- 
 form us, how the limb becomes lengthened 
 in consequence of these changes. I have 
 no hesitation in expressing my firm convic- 
 tion, that if the connexion between the 
 femur and os innominatum be loosened oi^ 
 
( 263 ) 
 
 destroyed in any way whatever, the muscles 
 attached to the former bone, would draw it 
 backwards and upwards, and thereby cause 
 a shortening of the limb. 
 
 And this objection applies to all the ex- 
 planations, which I have now been consi- 
 dering, whether they proceed on the sup- 
 position of a laxity of the orbicular liga- 
 ment, and effusion into the cavity; of a 
 tumefied state of the cartilages or synovial 
 gland ; or of a destruction of the articular 
 coverings and ligamentum teres. 
 
 The use which the patient still makes of 
 the affected limb in progression, and indeed 
 the free power of motion in every direction 
 which the femur still possesses, cannot fail 
 to occur to our minds, on the first exami- 
 nation of the subject, as an insuperable 
 objection to any of the explanations hi- 
 therto assigned ; all of which suppose a 
 removal of the head of the femur from its 
 acetabulum. This unimpaired motion of 
 the part is utterly irreconcileable with any 
 degree of luxation of the hip. Moreover, 
 
{ 264 ) 
 
 if the latter circumstance has really occur- 
 red, should we not expect a vacancy in the 
 natural situation of the head of the femur, 
 and a tumour in the part where it was un- 
 naturally lodged ? neither of which appear- 
 ances has ever been noticed at the period of 
 the complaint now under review. 
 
 The importance of the subject demands, 
 that the different opinions should be freely 
 investigated ; and it is my sincere wish, 
 that those, which I have promulgated, 
 should be tried, both by reasoning, and by 
 an appeal to facts. It will afford me satis- 
 faction to have any mistake of mine publicly 
 corrected ; and the moment I am convinced 
 of error, either in jodgment, or in practice, 
 the acknowledgment of my inaccuracies 
 shall be as public. 
 
 My own practice, and that of others has 
 afforded me a few instances of recovery 
 without lameness, after considerable elon- 
 gation had taken place. These facts are, 
 I think, very unfavourable to the opinion^ 
 
( 265 ) 
 
 which assigns a destruction of the cartilages 
 or ligaments as the cause of the lengthening. 
 
 I acknowledge my obligations to i)r. 
 Falconer, for the accuracy he has shewn 
 in making the following observations ; and 
 more especially for the use they have been 
 to me in investigating the real cause, why 
 the limb often appears elongated in hip 
 affection. 
 
 " Sometimes the breadth of the nates on 
 the diseased side is much increased, though 
 its prominence and firmness are diminished. 
 A man has the nates on the left side, at 
 least three inches wider than the right." 
 
 In two cases, now under my care, this 
 appearance of the hip is very visible ; and, 
 as far as I am acquainted with the subject, 
 this observation originated in Dr. Falconer. 
 
 The following is the paragraph, which 
 more particuiarly interests me : " The tu- 
 bercle, or lower part of the ischium, may, 
 in many instances, but not always, be dis- 
 
{ 266 ) 
 
 covered, bj feeling it behind to be lower on 
 tiie affected side, than the other. A man, 
 now in the hospital, is a remarkable in- 
 stance of the difference between the height 
 of the bones on each side ; and a pelvis of a 
 person, who died at the same place, and was 
 preserved there many years, shewed it still 
 more strongly.'* I confess, that this ac- 
 count puzzled me, and, I w^as induced to 
 wait upon my friend, Mr. Lawrence, re- 
 questing he w^ould give it every proper at- 
 tention. Mr. L. then mentioned to me a 
 conversation, which he once had on this 
 subject with Mr. Long ; in which that gen- 
 tleman informed him, that Mr. John Hun- 
 ter had attributed the lengthening of the 
 limb to the situation of the pelvis ; and that 
 he (Mr. Long) had found the observation 
 correct in every instance, in which he had 
 attended to that point. Not long after, two 
 cases of diseased hip in children came under 
 my care; and 1 felt particularly happy in 
 having Mr. Lawrence's assistance and 
 judgment in determining the accuracy of 
 Mr. Hunter's observations. 
 
( 267 ) 
 
 We instituted, in both these cases, a very 
 close and minute examination, and noticed 
 the following particulars : when the patients 
 were laid on the table, with the whole body 
 in a straight hne, the anterior superior spi- 
 nous process of the ilium on the affected side 
 was lower than that of the sound side, just 
 in proportion to the difference in the length 
 of the two limbs : this was about a quarter 
 of an inch in one patient, and a full inch in 
 the other. A similar obliquity of the pelvis 
 was equally manifest from behind, when 
 the patients were placed on the abdomen, 
 with the precaution of laying the body in a 
 straight line. It was impossible to place the 
 pelvis in its natural horizontal position, 
 without bringing the body into a curved 
 line, and when we did this, the lower ex- 
 tremities, instead of falling straight under 
 the body, deviated from the perpendicular 
 towards the diseased side. A straight line, 
 .drawn along the spinous processes of the 
 sacrum, and continued downwards, did not 
 fall between the lower limbs, as it would 
 in a pelvis possessing its natural position 
 
( 268 ) 
 
 and bearing, but it touched the heel of the 
 sound side. 
 
 The obliquity of the pelvis in these cases, 
 can, I think, be ascribed to no other cause 
 than that of the patient's endeavouring to 
 throw the weight of the bodv, as much as 
 possible, on the sound hip. The pain, and 
 the general weakness of the affected limb, 
 induce a constant effort of this kind; hence, 
 we observe children bending the knee and 
 hip, and hopping about on the sound limb. 
 The pelvis naturally sinks on the diseased 
 side ; and this deviation, which would affect 
 the centre of gravity of the whole body is 
 counterbalanced by a bend of the upper parts 
 of the trunk towards the sound side. Accor- 
 dingly, we found, that both the patients 
 inclined the head very manifestly over the 
 sound shoulder. 
 
 I have been thus particular in describing 
 these cases, to remove every idea of the ap- 
 pearances being supposed to originate in 
 inadvertency, inaccuracy, or want of due 
 examination. 1 flatter mvself that I have 
 
( 269 ) 
 
 thus given a more satisfactory explanation, 
 than has hitherto been offered to the pubUc, 
 of the manner in which the hmb in this 
 complaint becomes elongated : and I am 
 pleased that my examination of the subject 
 has tended to confirm the statement of Dr. 
 Falconer. The only motive, by which I 
 am actuated, is a desire of collecting useful 
 practical observations concerning the his- 
 tory and treatment of disease; and I al- 
 ways feel grateful to any person from whom 
 1 can derive such information. 
 
 The shortening of the limb, that comes 
 on in the latter stage of hip disease, has not 
 excited that difference of opinion concern- 
 ing its cause, which I have had occasion to 
 notice in speaking of the elongated state. 
 When the affection consists in a carious 
 state of the bones, the process of destruc- 
 tion goes on until the head of the femur i« 
 removed ; and then the muscles draw the 
 bone upwards and backwards, and produce 
 thereby a considerable shortening of the 
 member. Should the ligaments be the 
 parts more immediately concerned, they 
 
( 270 ) 
 
 are first destroyed, and the limb then un- 
 dergoes a real luxation, the head of the 
 thigh being drawn upon the dorsum of 
 the ihum ; this is the " luxation consecu- 
 tive" of the French surgeons. 
 
 The treatment of this malady is no way 
 different from that which is required in 
 similar complaints of other articulations. 
 The remedies are intended to prevent or 
 subdue inflammation, and to obviate the 
 occurrence of abscess. 
 
 The application of leeches behind the 
 trochanter and in the groin will have this 
 salutary effect ; abstracting blood by means 
 of cupping in the former situation, when 
 the state of parts will admit of the opera- 
 tion, has been found very beneficial. The 
 use of cold washes is very effectual in pro- 
 curing absorption of fluid, and an abate- 
 ment of pain : warm applications have to 
 my knowledge increased the sufferings of 
 the patient, and encouraged suppuration; 
 the wet cloths should be placed on the hip 
 and on the groin. 
 
( 271 ) 
 
 As soon as ease has been procured by 
 these means, a drain should be estabhshed 
 by caustic behind the trochanter, and it 
 should be kept discharging according to 
 the length of time required by the com- 
 plaint, or rendered prudent by the consti- 
 tution and age of the patient. If, as some- 
 times happens, whether the discharge be 
 maintained by blistering and the savin 
 cerate, or by the application of caustic, 
 painful symptoms should arise, these can 
 be removed by the antiphlogistic treat- 
 ment. 
 
 I have confined the afflicted by this com- 
 plaint wholly to their bed or couch, be- 
 lieving that the deformity so generally 
 produced by the disease, has been too 
 often augmented by suffering the patients 
 to bear on the diseased limb. 
 
 A wTiter* has conceived it necessary to 
 discriminate between the lameness inci- 
 dental to affections of the hip, and that 
 
 * Mr. Samuel Cooper on Diseases of the Joints. 
 
( 272 ) 
 
 which arises from curvature of the spine. 
 I should not have noticed his remarks on 
 this point because I cannot see any reference 
 which the two diseases can have to each 
 other. But when a surgeon points out a 
 distinction which he conceives worthy of 
 attention in practice, it becomes a duty in 
 every one to ascertain its accuracy, This 
 gentleman believes, that in curvature of the 
 spine, the weakness of the lower limbs 
 affects both sides at once, and is unattended 
 with pain about the knee, circumstances 
 completely discriminating this complaint 
 from the feeblenes of the limb, arising from 
 a disorder in the hip joint. 
 
 The opportunities, which my experience 
 has supplied, lead to a very different con- 
 clusion. In the very early period of verte- 
 bral affection, in which the spinous pro- 
 cesses have projected very little, I have 
 found one limb very little affected with 
 lameness, while the power of the other was 
 much impaired. Indeed in the more ad- 
 vanced period of this complaint, one limb, 
 in respect of paralytic affection, seems to 
 
( 273 ) 
 
 suffer more than the other: whether this 
 circumstance can be explained by the bo- 
 dies of the vertebrce being found more 
 distempered on the one side than on the 
 other, the student will determine for him- 
 self. If my reader should require infor- 
 mation from me to enable him to discrimi- 
 nate between these two complaints, let him 
 advert to the projection of the spinous pro- 
 cesses of the vertebrae in the one, and the 
 lengthened or shortened condition of the 
 limb in the other ; these remarks, together 
 with the attention which he should other- 
 wise pay to the state of the joint of the hip, 
 will prove unerring rules in practice, and 
 not fallacious, as must that judgment be, 
 which rests its conclusion on any circum- 
 stance connected with the lameness of the 
 patient. 
 
 The annexed representations of diseased 
 hips are taken from patients now under 
 my care. As they are merely designed 
 to exhibit the alterations which this afFec- 
 
( 274 ) 
 
 tion produces in the length and general ap- 
 pearance of the limb, I do not consider it 
 necessary to relate the particulars of the 
 cases. They are all in a state of progres- 
 sive improvement under the treatment, 
 which I have recommended in the pre- 
 ceding section ; and should any circum- 
 stance occur hereafter to make them de- 
 serving of communication to the profes- 
 sion, I shall publish them in one of the 
 medical journals. 
 
AFFENBIX, 
 
 L. Ford's publication on the Hip-dis* 
 ease, is a well written performance; and 
 the student will derive considerable prac- 
 tical information from its perusal. It was 
 with regret I noticed in it a translation of 
 the fifty-ninth and sixtieth aphorisms of the 
 sixth section of Hippocrates ; because it 
 appeared to me, that neither would the 
 disease bear Mr. Ford out in his interpre- 
 tation, nor could he be justified by the 
 original text in translating these aphorisms 
 in the manner he has done. 
 
 Mr. Ford says, in the sixty-third page of 
 his book, " I think I may venture to af- 
 
 T 2, 
 
( 276 ) 
 
 firm that the doctrine of Hippocrates, if 
 the aphorisms alluded to are liberally trans- 
 lated, is very clear and comprehensible to 
 those who are conversant with the disease, 
 and may amount to neither more or less 
 than what follows. 
 
 " Aph. 59. — In the progress of the hip- 
 disease, the standing out of the hip-bone, 
 or its external projection, and the falling in 
 of the nates behind are prognostics of sup- 
 puration. 
 
 " Aph. 60. — When, in this complaint, the 
 hip-bone stands out, the limb wastes, and 
 the patient must necessarily halt, unless he 
 be cauterized." 
 
 The latter aphorism should certainly be 
 considered as a supplement to the former, 
 and I am supported in this opinion, by the 
 different commentators on Hippocrates: 
 nay their very sense and meaning denote 
 the propriety of so arranging them ; and I 
 am almost inclined to think, that if Mr. 
 Ford had thus regarded them, neither he 
 
( 277 ) 
 
 nor his friend of Lisson Grove could have 
 possibly adopted the translations, which 
 have by them been offered to the public. 
 
 I shall first insist that the appearances 
 described in the fifty-ninth aphorism form 
 neither an indication nor a prognostic of 
 suppuration. 
 
 By suppuration may be understood the 
 formation or production of abscess; I have 
 never found it necessary in my own prac- 
 tice to advert to the figure of the limb, in 
 order to ascertain the existence of matter; 
 for the sensations of patients, their state of 
 health, and the fluctuation perceived in the 
 part, have rendered me acquainted vs^ith, 
 and themselves sensibly alive to, the nature 
 of their situation. 
 
 It is obvious that the latter aphorism 
 applies to a condition from which the party 
 might be relieved, and in which lameness 
 may be avoided ; now I am inclined to be- 
 heve that no such case of diseased hip, as 
 that described by Mr. Ford in his transla- 
 
( 278 ) 
 
 tion of the fifty-ninth aphorism, has ever 
 occurred without the patient being irre- 
 trievably maimed. I mean that in those 
 cases of hip-afFection, which have advanced 
 to the period of suppuration, the patients 
 have been irrecoverably crippled ; conse- 
 quently lameness could not have been pre- 
 vented by the application of the cautery, as 
 intimated and directed by Hippocrates in 
 his sixtieth aphorism. 
 
 Experience has taught me, that cases, in 
 the incipient stage of the complaint, may 
 recover, previous to the occurrence of sup- 
 puration, and thus that lameness maybe 
 altogether obviated. I could also adduce, 
 on this point, the testimony of other 
 surgeons. 
 
 The elongation of the thigh, the exte- 
 nuation of the limb, and the falhng in of 
 the nates behind, are characteristically re- 
 presented in Mr. Ford's first engraving, 
 in which it is proper to observe, that there 
 is no mark of suppuration. 
 
( 279 ) 
 
 The second plate is also a very just ex- 
 emplification of the appearance induced by 
 a carious state of the bones. The shortening 
 of the limb, and the outward marks of re- 
 peated suppurations are well depicted: and, 
 if there were any correctness in Mr. Ford's 
 translation of this aphorism, I will predict, 
 that the patient, whose case furnished the 
 drawing, will carry with him through life, 
 the prognostics of suppuration : as the pro- 
 jection of the hip, and falling in of the 
 nates behind, will remain with him to the 
 latest period of his existence. 
 
 These appearances are in fact, consequen- 
 ces of the disease, and never can be regarded 
 as prognostics of suppuration ; and, al- 
 though it be true, that the complaint may 
 have arrived at the height, which is intima- 
 ted in Mr. Ford's translation of the 59th 
 aphorism, and abscesses have occurred, yet 
 these collections of matter do not take place, 
 on account of the projection of the hip bone, 
 and the falling in of the nates behind, but, 
 are the ordinary effects of the disorder, with 
 
( 280 ) 
 
 all its ill consequences to health, and its de- 
 structive influence on the affected limb. 
 
 Should a knowledge of the disease give 
 me any advantage over Mr. Ford's friend, 
 and teach me, that the interpretation insist- 
 ed upon, by J. C. of Lisson Grove, cannot 
 be supported by the actual occurrences of 
 the complaint, I shall have done my duty, 
 as a practitioner of surgery, in rescuing 
 Hippocrates from the imputation of inac- 
 curate prediction, or of deficient informa- 
 tion on this subject. 
 
 If I speak confidently in favor of the 
 former translations, which have, until the 
 publication of Mr. Ford's book, been re- 
 ceived and considered, with no essential 
 difference, as expressing the true meaning 
 of these very aphorisms, I am justified by 
 finding, that Galen, and every commen- 
 tator on the works of Hippocrates are in 
 support of my convictions in favor of the 
 old translators. 
 
 In the first of these aphorisms, J. C. of 
 
( 281 ) 
 
 Lisson Grove, renders the word y.uL irotKiv 
 ilxTTiTTTsi, et retrorsum incidit, and falls in 
 behind. In support of this, he tells us, that 
 the word ttocXiv signifies retro, retrorsum and 
 contra behind, as it does rursum and iterum 
 again; but, from anj of the passages quoted 
 by him, we cannot see in what manner the 
 word, though it may be rendered retro, can, 
 with any degree of propriety, be translated 
 by the English term behind ; nor, do we 
 think, that this adverb corresponds with 
 the Latin retrorsum, which he uses. But 
 I. C. commits a greater error in his trans- 
 lation of the word fj^v^ai which he calls sup- 
 purationes. We apprehend, that it will 
 not be deemed too bold an assertion, when 
 we maintain, that the word can have no 
 such meaning: [jLv^ai implies strictly muci or 
 mucores, this signification is warranted both 
 by the derivation of the word, and its ac- 
 ceptation by the best commentators. 
 
 FoEsius, in the 254th page of that part 
 of his work, entitled, Qiconomia Hippo- 
 cratis Alphabeti serie distincta, defines i^^v^cc 
 to be " humor ille pituitosus et lentus qui 
 
( 282 ) 
 
 naturaliter in articulorum acetabulis conti- 
 netur/' he adds, moreover, the following 
 emphatical words by way of ilkistrations 
 *' mucus aut mucor, qui cum purus sit, et se- 
 cundum naturam se habeat, bene valentes et 
 facile mobiles articulos reddit : ac si contra 
 naturam succreverit et redundarit, nimio 
 humore articulorum ligamenta imbibens et 
 lubricans, eorum prolapsiones facit. Sic 
 aph. 59. lib. vi. /xuja et mucores superve- 
 nientes femoris caput loeve et lubricum 
 reddentes, in causa sunt ut facile sua cavi- 
 tate excidat." 
 
 Mv^u, as appears in Gorraeus, signifies 
 that " mucor qui est in articulis, in spatiis 
 internis continetur" and not suppuration.* 
 I will subjoin the words of Gorraeus, i^v^u 
 mucor, mucus dicitur ab Hippocrat. hu- 
 mor pituitosus, lentus et albus. Is in 
 partibus exanguibus, ossibus et cartilagini- 
 bus colligi consuevit; cum ad earn imbe- 
 cilitatem pervenerint ut alimentum suum 
 nequeant concoquere. 
 
 * Vide Gorraei Opera sub voce (av^» 
 
( 283 ) 
 
 After these proofs of the clear and plain 
 meaning of the word /xi^Ja/ we are rather 
 surprized at the pertinacity with which 
 J. C. insists upon the propriety of ren- 
 dering it suppurationes ; wishing, however, 
 to bring this matter to a conclusion we 
 beg leave to quote a passage from the ap- 
 pendix to Mr. Ford's observations on the 
 disease of the hip joint. In page 250, we 
 find J. C. expresses himself thus ; " to the 
 rendering the word /^i^Ja/, which I have 
 translated suppurationes, although it has 
 various significations, there cannot, I be- 
 lieve, be any solid objection : in vindication 
 of the sense in which I have taken it, I 
 appeal to Gorraeus, who expounds it in the 
 same meaning with regard to this very 
 aphorism." 
 
 In answer to the above, we deny that 
 the word has various significations; it sig- 
 nifies muci and not suppurationes, conse- 
 quently there is every objection to its bein^ 
 translated suppurations. 
 
 If J. C. should feel himself aukwardly 
 
( 284 ) 
 
 situated, he is rendered so, bj his friend, 
 Mr. Ford probably not acquainting him, 
 that mucus and pus are distinct things. 
 In justice to J. C. however, it ought to be 
 stated, that a gentleman, pre-eminently dis- 
 tinguished by his profound knowledge of 
 the Gr^ek language, would, when I stated 
 the question, have committed the same 
 error, but for my explanations, conceiving 
 that mucus or pus might be used indiffe- 
 rently; from this circumstance it maybe 
 surely inferred, that, however eminent a 
 man may be for Greek literature, he is not 
 therefore sufficiently qualified to judge of 
 medical subjects, unless assisted by other 
 advantages. 
 
 It is really a matter of astonishment, 
 that an appeal should have been made to 
 the works of Gorrceus ; in which I posi- 
 tively assert that there will not be found 
 any thing which could, by the most forced 
 construction, justify us in assigning any such 
 meaning to the word [jlv'^ui as the matter 
 produced by suppuration, or pus. I am 
 at a loss to conceive, unless J. C. acknow- 
 
( 285 ) 
 
 ledges that he is unacquainted with the 
 distinction which medical men have esta- 
 blished between pus and mucus, what apo- 
 logy he can offer for such an unwarranted as- 
 sertion as, '' thus you see that there is not 
 a single word of any importance which I 
 have warped, violated, or translated at my 
 own peril." 
 
 Having thus, 1 trust, shewn the impro- 
 priety of adopting either Mr. Ford's, or his 
 his friend's translation from the authorities 
 which they themselves have produced, I 
 shall take the liberty of referring the reader 
 to any of the old commentators on the 
 works of Hippocrates, for they all, without 
 any material difference, agree as to the pro- 
 per interpretation of these two aphorisms. 
 
 Dr. Falconer of Bath has taken notice 
 of these very aphorisms in his dissertation 
 on Ischias; as his construction certainly 
 favors these gentlemen's translations, I 
 think they are justly entitled to every sup- 
 port Dr. Falconer's opinion can possibly 
 supply. 
 
( 286 ) 
 
 The Doctor expresses himself thus, " in 
 the sixth section of the aphorisms of Hip- 
 pocrates, there are two that refer to this 
 disease, which, I think, have been mistaken 
 by the translators, who have expressed 
 themselves, as if there was an entire dislo- 
 cation of the head of the bone, when the 
 word* implies no more than a projection, 
 which is indeed a partial dislocation. The 
 meaning of Hippocrates, is, I think, clear 
 enough, that if the head of the thigh-bone 
 be at first considerably protruded, or, as he 
 expresses it, stands out, and again sinks 
 back (suddenly, as I think implied) into the 
 socket or acetabulum, it indicates a suppu- 
 ration to have taken place ; and this, 1 take 
 to be true, provided, as we may reasonably 
 suppose, that Hippocrates meant, that 
 there be no general amendment or abate- 
 ment of the symptoms." 
 
 It is really painful to my feelings, that I 
 should again advert to these aphorisms, but, 
 with due submission to Dr. Falconer's ex- 
 
( 287 ) 
 
 perience, I can no more adopt his opinions, 
 than those, which 1 have before objected 
 to. It is a pity, that men of professional 
 abiUtj, and others of hterary attainments, 
 should be so unmindful, as to neglect the 
 poet's advice to " speak no more than is 
 set down for them :" if this admonition had 
 been attended to, I am satisfied, that an op- 
 portunity would never have been afforded 
 me (as a practical surgeon) of defending 
 Hippocrates against a charge of profes- 
 sional ignorance, want of sense, and incapa- 
 bility of prediction, which, in my mind, is 
 implied, could it be supposed, that his mean- 
 ing was in fact that adopted by either of 
 these gentlemen. 
 
 It is rather curious, that it never occurred 
 to them, that the meaning of an author can 
 be only ascertained by what he himself says 
 on the subject. The reader will readily see, 
 that all the objections, which have been 
 made to Mr. Ford's and I. C's translation, 
 apply equally to that of Dr. Falconer. I 
 have great respect for the Doctor's medical 
 skill, but surely his surgical reputation is a 
 
( 288 ) 
 
 little impeached, when he states, " that the 
 membranes, which were at first thickened 
 bj inflammation, and which thrust the head 
 of the bone outwards, being melted down 
 by suppuration, allow it to fall back again 
 into the socket, from whence it had been 
 pushed by the thickening of the periosteum, 
 or of the lining of the cotyloid cavity." 
 And again. Dr. F. observes, *' the succeed- 
 ing aphorism implies no more, than that 
 hip cases of long continuance, and accom- 
 panied with a projection of the head of the 
 bone, are apt to induce lameness and wast- 
 ing of the limb unless a cautery be used.*' 
 
 A man must possess vast credulity, and 
 little acquaintance with surgery, who can, 
 for a moment imagine, that the application 
 of the actual cautery, could possibly have 
 the power of preventing the occurrence of 
 lameness, should the patient ever have been 
 affected in the manner Dr. Falconer has 
 described. 
 
 It may be objected, that more has been 
 said with respect to these aphorisms, than. 
 
( 289 ) 
 
 in a practical sense, they may seem to de- 
 serve ; but, I beg to remind the young sur- 
 geon, that his reputation will be no less 
 hazarded by an unfortunate prognostic, than 
 if he had committed an error in practice. 
 
 Mr. Ford has judiciously requested a 
 learned friend, whose impartiality is the 
 more to be respected, as he is not of the 
 medical profession, to furnish him with a 
 new translation of these aphorisms, that 
 coincides with his own opinions. I also 
 have propounded the matter to a divine, 
 whose character for Greek erudition, were 
 I at liberty to disclose his name, every En- 
 glish scholar would revere ; and, as I find 
 that his idea of the sense of Hippocrates 
 differs from that of J. C. and agrees more 
 nearly with the commonly received trans- 
 lations, I shall lay his opinion, and the au- 
 thorities, by which he supports it, before 
 the public ; and leave those, who are inte- 
 rested in the controversy, to form their own 
 judgment. 
 
 u 
 
EXPLANATION OF THE PLATES. 
 
 The figures, illustrative of the hip- affection, exhibit the 
 appearances of the limb under the three circumstances de- 
 scribed in the last section. 
 
 Plates 1. and 2. furnish a very correct view of the in- 
 creased breadth of the nates, as described by Dr. Falconer 
 in his treatise on Ischias. 
 
 Plate 3. represents the elongated condition of the limb 
 with the flatness of the nates, and the general extenuated 
 appearance of the whole member. 
 
 Plate 4. shows the shortened condition of the thigh, 
 the patient having undergone repeated suppurations. In this 
 case the thigh bone was anchylosed with the ischium. 
 
 Plate 5. — An engraving taken from a drawing of the ap- 
 pearance of the case of spina bifida, mentioned in Mr. 
 Langstaff's letter. The inner circle represents the ulce- 
 rated surface described by that gentleman. 
 
 Plate 6. Fig. 1. and 2. show the manner in which the 
 spine was defective in the case of spina bifida attended by 
 myself, as described in the section. 
 
 Plate 7. — The bones which furnished this drawing were 
 taken from the body of a patient who had been under my 
 care, and who died, some years after the cure was effected 
 by the caustic issue, of some other distemper. The reader 
 will observe, that there are seven spinous processes, and four 
 bodies only, so that the patient must have sustained a loss of 
 three bodies more or less. I have given this preparation to 
 Mr. Lawrence, who has deposited it in the Museum of St. 
 Bartholomew's Hospital : — It is an excellent specimen to 
 show that there is no renewal of bone to supply that removed 
 by the disease. 
 
 ERRATA. 
 
 Page 13, line 13,/or verterbrae, reat/ vertebrae. 
 
 18, 23, for inflamationem, read inflationem. 
 
 27> 9> Z""" oedeniatious, read oedematous. 
 
 59, 2, for andvantages, read advantages. 
 
 104, 2, for scroufulous, read scrofulous. 
 
 122, 2, for savine, read savin. 
 
 I a 8, 4, for ereta, read erecta. 
 
PZ<a^ .1 
 
 •aN 
 
 J\.Il^J^2Je^:^ '^2ei>7.^J.Ca7lo,^.CW,^» Cou^ Prtncs Stn^t 
 
m 
 
 J^^laZe . 2 
 
 W^'" 
 
 v.-^': 
 
 «» Cii^fa.iid. 
 
 J.Sai&ar. -ttvJh - 
 
 IMli,>u^]}^^:IfJg&7.ly J.CJl^.C^u„.Ci»^IU^„^ S/^^ct 
 
Plate. 
 
 T'ullUiUJJec '.SflSe? ^ J.C,.V.:„-r,^.„ (Wrtii^H^St,^ . 
 
I'/a/^-. J 
 
 m 
 
 t7.Sa:2Mza7^.sti^7/>. 
 
 2'fil7is^e.7IJec:\3^^2^^r^-yJ.C^/7.'^^rrrnynC^r9-I^z. 
 
I'la/rr 
 
 '^Ca.rn:ieU.cld. 
 
 J.-'faiUUr-..-^.'^. 
 
 :BMiA^J)ec r^ ^28e7.iyj:CaUm:Cnn<nCiu>irn?tc-es Sirefl 
 
FlaU 6. 
 
 lio-. I. 
 
 Fig. 2. 
 
 K.Fishjer del. 
 
 J.SinlHar soi^. 
 
 luhUshedDarijfjSoj. byJ.CaJlmv. 6-omi (hurcTi-irMs Slivet, Soho. 
 
/'/«//• 
 
 TlF,.^^fr.iel. 
 
 x/'.Sa-ii'i-izp- 
 
 J'uUY^i^dJ>a!y7^'j'8fl7. iyJCaTlm'. Crm-n Ceru.-ri^IUnan' SfretT. 
 
NOTE. 
 
 MCuiBUS k diuturno coxendicis morbo vexatis coxa ex- 
 " cidit et rursus incidit, his mucus innascitur." Hipp. Aph. 
 
 " Glasguas, ann. 1748. Jans, ab Almeloveen. " Quibus 
 
 " longo coxendicum dolore conflictatis feraoris, summum 
 " coxje excidit rursumque recidit, lis mucores innascuntur." 
 Hipp. Aph. Vorstii. Ludg. Batav. ann. cididcxxviii.— — . 
 " Quibus ab ischiade diuturno vexatis ischium ^ proprio loco 
 *' excidit atque rursus incidit, iis muci innascuntur." Trans- 
 
 latio Charterii " Quibus longo coxendicum dolore con- 
 
 *' flictatis, femoris summum coxae excidit rursumque recidit, 
 ** iis mucosa ibidem pituita colligitur." Translatio HoUerii, 
 
 Rejecting these translations, J. C. proposes his own in the 
 
 following words : " Morbo coxario diuturno laborantibus, 
 ** femur extat, et retrorsum incidit; his superveniunt suppu- 
 " rationes." " In persons afflicted with a lingering disease of 
 " the hip-joint, the hip stands out, and falls in behind ; ia 
 " them suppurations follow." The learned author observes, 
 that Hippocrates uses the word Jo-p^/oy laxly; that i|/s-«/Aa< sig- 
 nifies extare, to project or stand out, as excidere, to fall out; 
 and that 'ua.Xiv as certainly signifies retro, retrorsum, and co7i- 
 tra, behind and on the other side, as it does rursus and iterum, 
 cgain. 
 
 According to my opinion, the sense of Hippocrates may be 
 ippre accurately expressed in the following words : ** la 
 
( 292 ) 
 
 ** whatsoever persons afflicted with a disease of the hip-joint 
 " of long continuance, the hip-joint stands out (from its usual 
 " situation) and falls back again into it; in them, mucuses, or 
 " mucous secretions, are attendant symptoms." For my in- 
 terpretation of la-^iov I will quote Focsius: " Interdum oiJt.'Jiv'JiJi.ov 
 *' esse oiiiTu Ttf ro <x§9§oy' sic enim la-^lov iKirliilm dicitur, lib. de 
 " art. [pag. 6'38. 12. H. 825. 6.] oivri t« xar Itrylo)) oi^^^a, 
 •' ut illic scribit Gal. Et. Aph. 59- & 6o. lib. 6'. to 'tayjov I|*t«t«/ 
 " iC, 'usxXtv iixmiilH' coxa cavitate sua excidit, rursusque reci- 
 *' dit, hoc est, to kxt ia^lov ci^O^ov coxendicis articulus, ut illic 
 " scribit Gal. Sic enim de femoris capite et summo intelligitur 
 " quod cox£e inserilur, et excidere rursusque illabi potest quo- 
 " modo etiam libr. de art. al/^a a,^9§ov elabi dicitur humeri ar- 
 *' ticulus «vT< tS x«t' ftJ/M-ov a^Q^H pro articulo qui est ad hume- 
 " rum. A^d^ov, namque eo aphorismo totam articulationem 
 " significat quce complectitur et caput femoris rotundum ac 
 " laeve et acetabulum et vinculum : idque totum i(7;^/'ov ibi 
 " dicitur." 
 
 Because the English word " lingering" conveys the idea of 
 pain and debility, as well as duration, I would render y^^wiyis of 
 long continuance. I admit that I see that extat more accu- 
 rately represents the Greek word £^/s-«t«; than excidit. It ex- 
 presses the appearance of the diseased joint, and the effect of 
 the disease upon it. 
 
 In regard to 'ct«^<v, the passages which J. C. quotes from 
 Homer, and those to which he refers in other writers, shew 
 that it means retro ; and I would observe, that rursus in the 
 sense of retroversus, sometimes means more than the mere 
 repetition of an act as expressed by iterum. But as in the 
 case stated by Hippocrates, the joint returns into its former 
 situation, I have endeavoured to avoid all ambiguity by trans- 
 lating 'aa.Kiv back again. I do not agree with J. C. in render- 
 ing the word ■aaXiv behind. Nor do I see how the English word 
 
{ 293 ) 
 
 corresponds to tlie Latin word retrorsum, which he has himself 
 employed. But further, though it were granted that z:a.Kiv 
 sometimes means behind or on the other side, yet, in the passage 
 we are now considering, I should not assign to it such a signi- 
 fication. For IfAviTfleiv, though it well expresses the falling in 
 of the bone to its proper situation, is very ill calculated to 
 express the sinking in of the part of the hip opposite to that 
 which stands out, — ■ — Mv^x, as appears from Gorrseus, signifies 
 that " mucor qui est in articulis, aut in spatiis internis conti- 
 netur," and not suppuration. I will subjoin the the words of 
 Gorragus: ^^ Mv^x mucor, mucus dic'itur ah. Hippocrat. humor 
 " pituitosus, lentus, et albus. Is in partibus exanguibus, 
 " ossibus, et cartilaginibus colligi consuevit, cum ad earn im- 
 " becillitatem pervenerint ut alimentum suum nequeant con- 
 " coquere." 
 
 That (Av^x does not signify suppuration ; that it does signify 
 mucous secretion, and that the excess of secretion is inju- 
 rious to the joints, will appear plainly and fully from the words 
 of Hippocrates : — " Mv|« tsoiuiv i?\ ^vasi' ycxi orxv ctxifn xxOx^ii ri, 
 " vyixivovjt rx xgQqx, y.xi S/« tSto ^txnmrx If'Vj ^re oXiaaxivovrx 
 " -STfos luvTcH'. '^^ovos Se x.xi o^iivifi ytnrx:, orxv dvo Tr,s ax^icos vy^xari 
 " pvH zyovyiaxan to ■cr^aiTov //.riv 'zsriyvvrxi to x^9^ov' oii yxg IXia^fi^ii n 
 " vyporvis v lirilfivriKvix xnro T^y Tapxoy 'iiTHTx ufB ctoXXd Xivtv v£^o^e»»), 
 •' y.x\ tiK «fSo//,Em sx. TYis (Txpyios «£( ^ripxiverxi' y.»t a^fs ZToXXv sna-x, 
 " KXi ov ^u^ZvTos t5 K^d^a sx-^ei, kxkus 'ZSs'Tftiyvtx, ftET£wf/^« Tx 
 " vsvpx, oTai TO x^O^ov crvv^i^BTxi, kx) x^irx zsotH kxi dixXiXvf/.evx, 
 " KXt^tx t5to yr^uKoi yivoylxi' y.xiorx> (xh tSto (jlxKXov yinrxi,(/.xXXov, 
 " orxv h rta-a-ov, ?>a<rov. Mucus omnibus a natura inest, et 
 " cum purus fuerit, bene valent articuli, ideoque facil^. mo- 
 « ventur, cvim sint inter se lubrici. Oboritur autem labor et 
 <' dolor, ubi vexaverit quas kcarne fluit humiditas. Imprimis 
 «^ quidem rigidus fit articulus, neque enim lubrica est quse ex 
 ^' carne effluxit humiditas, Deind^ sua copia vald^ dispersa, 
 
( 294 ) 
 
 " neque a came irrigala, semper resiccatur ; cumque earn ob 
 " multitudineni articulus capere non possit, effluit, maleque 
 *' concrcscens, nervos quibus articulus connectitur, attollit, 
 ** elaxat, et dissolvit ; eamque ob causam vel majus, vel mi- 
 " nus, claudi fiunt." Hipp. p. 411. 
 
 As to the concluding word in the aphorism of Hippocrates, 
 I conceive that neither innasci nor colligi, which occur in some 
 of the translations, convey the meaning oiltrtyincrGixi. I should 
 object also to the English word follow, proposed by J. C. be- 
 cause it seems to denote mere succession. The Latin word 
 supervenire, which J. C. has employed, appears to me less ob- 
 jectionable. But the real and appropriate sense of the Greek 
 wftrd will be best collected from the two passages I shall quote 
 from Gorraeus and Foesius : " ^^itiy'mi/.»' idem quod wiA.'nruyua, 
 " quanquam aliqui ita distinxerint ut symptoma esset quic- 
 *■' quid praeter naturam animali accidit : tTitymyux, vero non 
 " omne sed quod solos morbos necessario sequitur. 
 
 **■ Hoc vocabulum purum est in usu apud Graecos, ait Gal. 
 ** lib. de different, symptom. Ab illo factum lwy/W9a/ quod 
 " apud medicos de symptomatibus dicitur qua ipsius morbi 
 ** augescentis ratione accidere solent, ait Gal. Aph. 35. lib, 6, 
 " MfTawTrJftwero, Gum, soluto priore affectn, alter novus inci- 
 
 " dit, ut notat Gal. in Aph. 11.1.7. Gorraeus," " 'Ew<y/Wd«i 
 
 " est supervenire, succedere, et de iis dicitur quae in morbis 
 ** accidunt, proprieque de his quae morbi ratione et auctse 
 " passionis nomine" succedunt. Gal. Com. ad Aph, 35. lib, 6. 
 " i'ffiylna-Oaci rois tsraflsu/v irt^oi tseiGvj t» xa/ fff/xTrTw/xasla rots 
 ** 'axXams i*it§o7s 'ides Ifi >>.cyHv oaa, xmto. tov «fT» njciOois f^iyov 
 ** eu%a,wi*.iDa cv[jiSahm t'l'uds. — Morbos et symptomata morbig 
 " succedere veteres medici dicere consueverunt qu£e ipsius 
 " morbi augescentis ratione accidere solent. Hi nc Iw/y/vo/Atva 
 " dicuntur quas morbis necessario, eorumque increscentium 
 
( 995 ) 
 
 ■' ratione succedunt, eosque ex necessitate comitantur non 
 " symptomata simpliciter." 
 
 I doubt whether the English language has any single 
 word which definitely and completely expresses the meaning 
 of tmyivovlxi as used by Hippocrates, and therefore, with the 
 advice of a learned person, I have said ♦' are attendant symp- 
 " toms." But I wish the medical and the critical reader to 
 observe that inifmiT^xi implies not merely the concomitant, 
 but necessary and aggravating circumstances of a disease. 
 
 FINIS. 
 
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