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ment of the wound, the detached part ofthe brow healed below the level of therest; producing a remarkable and by nomeans becoming appearance. This gen-tleman, who was handsome, rejected myadvice of letting it remain as it was, andwished me to adopt any proceeding forremoving the deformity. I made a ver-tical incision on each side of the displacedpart, united the incisions transverselyabove, and dissected off the portion fromits new situation, leaving it adherent be-low. Of the flap thus made I cut offthe upper portion, corresponding to thedepth of the eye-brow; and then securedthe remainder in its proper position bysutures. It adhered readily, and the

operation seemed to have succeeded per-fectly, when the patient left England fora long absence on the continent.

In wounds of the brows and lids, adhe-sive plaster is not sufficient for keepingthe parts in exact apposition; it will benecessary to unite them by sutures, suchas will not irritate the parts, using small,thin, sharp-cutting needles, with singlesilk threads. You will employ such a num-ber of sutures as may be necessary tounite the parts in their proper relation toeach other. Lay over the part soft linenrag dipped in cold water, use this ap-plication frequently, keep the patientquiet, and attend to his bowels. You

may cut out the sutures in eighteen ortwenty-four hours; that time will be suf-ficient to accomplish the purpose of pro-moting accretion, as the edges of thewound will be agglutinated either by co-agulated blood or coagulable lymph.-By removing the sutures you will avoidall irritation from that source, whichdoes not come on in so short a time.You will be surprised in many cases tosee how speedily and completely theunion of the parts is effected by adopt-ing these measures. The mode of pro-ceeding I have recommended’ is particu-larly necessary in wounds of the lid, inwhich it is more difficult to preserve anaccurate adjustment than in wounds ofthe brow.

ERRATUM in Mr. LAWRENCE’s last Lec-ture.

Page 468, ten lines from the bottom,for "prescribed," read proscribed.

LECTURESON THE

THEORY AND PRACTICE OF PHYSIC,

BY DR. CLUTTERBUCK.

Theatre, General Dispensary, Aldersgate-street.

LECTURE VIII.

Gentlemen,AT my last lecture I was speaking of

the various ways in which diseases occa-sionally prove fatal ; I remarked, thatsometimes death takes place in conse-

quence of some function, essential to life,being interrupted, and that it is on thisaccount that diseases of the lungs, heart,

and brain are comparatively more dan-gerous than others.i Another way in which disease mayprove fatal is, by the general irritationthat is excited by it ; of this we have buta very indistinct idea. We find that dis-eases occasionally prove fatal, althoughthey are seated in organs that are notessential to life. I illustrated this by re.ference to cases of extensive burns, wherethe skin is the part injured ; such casesoftentimes prove fatal, and we ascribethe fatal termination to irritation, (whichis the intermediate cause,) withont beingable to show how this effect is produced.The skin is not a part the functions ofwhich are immediately essential to life ;death cannot, therefore, be produced bythe interruption of its functions. The

brain, in these cases, appears to suffer,for in such as terminate fatally the stuporand delirium that occur sufficiently ifldi-cate this organ to be affected.Again, diseases may prove fatal by the

weakness which they indnce, and that indifferent ways. Most diseases consist inexcessive, as well as disordered, actionof the affected part ; and this excess of ac-tion, by degrees, exhausts the vital power.It is in this way that long continueddiseases, of almost all kinds, graduallyreduce the strength, so as at length toprove fatal. In like manner, pulmonaryconsumption does not in genera) destroylife, by absolute destruction of the hmgs,so as to render them altogether incapableof carrying on their functions, (tbr asmall portion of lung is sufficient to sup-port life,) but by the continued state otexcitement that is taking place through-out the system, and consequent exhaus-tion of the vital power. Another caRseof weakness exists here, namely, th,

503

general disorder of functions that neces- xsarily atteods such a preternatural state 1of vascular excitement so that, whilethe body is wasted on the one hand it is

imperfectly nourished on the other. IThe greatest degree of weakness, how- I

ever, is induced by disease in those or- fgitns upon which the supply of the systemparticularly depends; ttms, in the scir-rbous state of the stomach, food, if taken,cannot be well digested, so as to be fitted 1

for the purposes of the system. Again, inscrofulous habits, the mesenteric glandsbecome enlarged, producing those large

bellies observable in many children, andby which the lacteal vessels are com-pressed, and thereby rendered nearly

1

impervions. In these cases, although theappetite is often ravenous, and food istaken in great abundance, the body ue-vertheless wastes, and the greatest ema-ciation takes place, in consequence of thechyle being interrupted in its passage intothe system.Lastly, diseases may prove fatal by

accidental circumstances, arising duringtheir course, and which could not havebeenforeseen. In pneumonia, for exam-ple, haemorrhage from the lungs may takeplace and prove fatal, either by imme-diate suffocation or by the quantity ofblood lost, though this latter is a rarepecurrence. In fever, likewise, the arte-rial system of the .brain being in a stateof intlammatory action, one of the bloodvessels may give way, and, blood bpingeffused, apoplexy may ensue. Suchevents are always liable to happen, evenin the slightest cases, so as to disappointour hopes. Now there is an advantagein your knowing this, because it makesyou cautious in your prognosis.

Sometimes diseases terminate in oneanother, and in this way may prove fatal;for example, pulmonary consumption fre-quently succeeds idiopathic fever, andthe transition from the one disease to theother is sometimes hardly perceptible ;you should be watchful, therefore, at theclose of fever, in order to detect andobviate such occurrences by every pos-sible means, and at the earliest moment.Diseases sometimes prove fatal by sud-

denly shifting their seat. Thus, for ex-ample, inflammation seated in the liga-mentous structure is apt to be translated,as it is termed, to some internal part, asthe heart, or lungs, or brain. This sud-den translation, or shifting of disease, iscalled metastasis, and often takes placein gout and rheumatism, when these dis-eases are improperly treated.Some diseases are naturally incurable,

but may nevertheless be removed by art.’Of this kind is syphilis, which progres-

ively becomes worse, unless it he stopped)y the use of mercury, or other adequateaeans.

,

Some, on the other hand, are incurable)y art, but terminate spontaneously inhealth, after running a certain course.

Such is the case with small pox, hooping’oogh, and some other specific diseases.Lastly, there are some diseases that haveno disposition to subside of themselves,nor have we at present any remedy forthem; this is the cese with cancer andwith hydrophobia, which therefore neces-sarily prove fatal.

It must now; I think, be obvious to

you, that in order to be able to predictthe event, or, as it is technically called,to give a just prognosis, (a circumstancein which the reputation ef a practitioneris deeply involved,) yon must make your-selves intimately acquainted with the

history of diseases, not generally merely,but individtially, and this you will find isequally necessary to successful practice.

I shall proceed now to speak of themanner of treating diseases.

Of the Treatment of Disease in general.I am here, gentlemen, to speak of those

general principles of cure which are cora-mon to all diseases. Now you must re-call to your recollection what I beforeobserved, that the treatment of diseasesdoes not necessarily consist in the em-

ployment of remedies, nor always in en-deavonring to effect a cure; for, 1st, at-tention to regimen is sufficient for thecure of many diseases ; and, 2dly, someit is not prudent to remove if one could,as where the disease has proved curativeto another of more importance. For ex-

ample, during the course of ordinary feverit not unfrequently happens that an in-flammation appears npon the skin, eitherin the form of phlegmon or of erysipelas,and the fever declines in consequence.If, in sueh a case, we were to remove thesecondary affection, we should run a.tiskof bringing back the fever, which is moredangerous than the inflammation on theskin. It is npon the same principle, thatwe rather allow the gout to take itscourse than attempt to suppress it byhasty measures, as we know that it willin general soon terminate of itself; andfurther, because experience has shownthat the hasty suppression of this diseaseis often followed by diseases of greatermagnitude. The same objection appliesto diseases that have become habitual,such as old ulcers, cutaneous disorders,and hæmorrhoidal affections.

Supposing, however, that it is properto attempt the cure, you may proceed indifferent waye, and sometintes upon dif.

504ferent principles. In the first place, youought, if possible, to remove the cause,where it is still acting. In some cases,the removal of the cause is tantamount toa cure ; and it is, therefore, always pro-per to attempt its removal, as its conti-nued application is often sufficient to

keep up the disease. I may illustratethis by reference to a simple case of oph-thalmia, arising from an inverted eyelash,or any foreign matter underneath theeyelids. It would, in this case, be vainto expect the removal of the diseasewhile the cause remains. Again, inflam-mation of the mucous membrane of thealimentary canal, may be kept up by ir-ritating matters lodged there, and it isproper, therefore, to commence the treat-ment of such cases, by the administra-tion of a purgative. So in diseases thatare the result of sudden changes of tem-perature, (taking cold, as we call it,) thereis generally an advantage in keeping thepatient in a regulated atmosphere. Thereare, however, some causes which can-not be removed; for example, inflamma-tion of the kidney is often brought on,

it, because it proves that the disease ison the decline, and it then generallyterminates favourably. Accordingly,dif.ferent modes of treatment have beenadopted in imitation of this. Inabdomi-nal inflammation, purging is the most im.portant means of cure, as it is imitatingand promoting the natural termination ofthe disease. So also, in diseases of theorgans of respiration, expectorants aregiven to promote secretion from the mu.cous membrane of those parts. A hastysuppression of these discharges is com-monly injurious, and on this account it is,that opium is rarely proper in the earlystages of either catarrh or diarrhaea, asit tends to prevent the increased secre.tion, which is the natural termination ofthose diseases. 5thly. Another principleupon which we often act is, the endea.vouring to cure the disease quickly; apurpose which may be effected by diffe.rent, and even opposite means; thoughone mode may be better than another,according to circumstances.As diseases consist primarily andes.

sentially in disordered action, and theconsequences of this, our object is, in thefirst place, to put a stop to the disorderedaction, if this should still be going on,and then to endeavour to remedy theeffects. You will find this distinctioBvery much neglected in general practice,and I could give you a hundred instancesin proof. In dropsy, for example, pro.duced, as it is in a majority of cases, hyinflammation, you will often see practi-tioners stimulating the patient in variousways, in order to promote absorption,

. while they overlook or neglect the inflam-

. mation, (though still subsisting,) uponwhich the dropsy depends. In the same

way, you may daily see attempts made tosupport the system, and keep up the vis

vitœ (as it is absurdly expressed) infevers, by wine, and bark, and campliorand the like ; although the depression ofstrength is merely an effect of an inflam.matory condition of the brain, which sti.mulants and tonics do but tend to aggra.vate.

The putting a stop to the diseased ac.tion may be accomplished in two ways.We may either act immediately upon thepart affected, or else through the mediumof other organs ; so that we have a directand an indirect mode of citie, or, in otherwords, the treatment may be local, or itmay be general. In external diseases,we often have recourse to local treatment,but in internal diseases, we cannot alwaysact in this way. In diseases of the heart,lungs, brain, and kidneys, local treat.ment is seldom practicable; we havelittle or no access to these parts, and are,

and kept np by a calculus lodged there;in this case, we have no power to curethe disease, because we cannot removethe cause ; our treatment, therefore, is ofnecessity merely palliative; 2dly. In thenext place, you must regulate the regi-men of the patient; as in regard to air,temperature, food, &c., all of which areof importance, because the neglect ofthem .may frustrate the best means ofcure. 3dly. The disease may be allowedto go through its natural course, thepractitioner contenting himself with re-moving obstacles, guarding against acci-dents, and palliating particular symp-toms, when this can be done without in-jury to the actual disease, (expectant me-dicine, as the French physicians call it.)Now this applies to fevers, when theyhave become fully formed-to gout, andmany othel s. Cautious and timid prac-titiouers proceed much in this way, fromthe fear of doing harm, and from havingsuffered repeated disappointments. Thismode of practice is often attended withsufficient success to give a considerableshare of reputation to the practitioner,and is much pi eferabte, indeed, to the op-posite extreme, of unreasonable conti-deuce in the use of- powerful medicines,for these are capable of doing muchharm when misapplied. 4thly. We maygo a step further, and imitate the naturalcure, or termination. Many diseases gooffin a certain way ; for instance, inflam.mation of the ii ncons membrane gene-rally terminates by increased secretion.Whenever this occurs, we are glad to see

505

therefore obliged to resort to indirect, orgeneral means of cure. This, at first,appears a serious disadvantage ; but it isnot so in reality, as yon will presentlyperceive.

, Local treatment, when it is applicable,

may consist in any means that will tendto change materially the action of the

part, as by stimulating it variously ; orthe reverse, as by the application of cold,or other sedatives. Or we may endeavou-vour to excite discharges of any kind,from, or near to the part. Another kindof local treatment might consist in inter-cepting the supply of blood to the part,by ligature or compression, or division ofthe blood-vessels ; could this be done,there is no doubt that it would be iiiglityefficacious, especially in inflammation,but it can seldom be put in practice.The indirect or general treatment, eou-

sists in making powerful impressions upon, the rest of the system, or particular partsof it, and this is often followed by a ces-sation of disease. Fortunately, we can aswell and powerfully influence diseasedparts by indirect, as by direct means.This would hardly occur to you, perhaps,atlfirst,yet experience sufficiently provesit. Thus ophthalmia is more successfullytreated by general remedies, such as

bloodletting, purging, and blistering, thanby any local treatment. It is not, there.fore, of much importance in general,whether we have immediate access to the

part or not; in fact, all our most power-ful means of cure, are of an indirect kind.Bloodletting, vomiting, purging, and

blistering, are of this description. These,by making a powerful impression on aparticular part of the system, change its’ condition and mode of acting. The change

thm induced, affects by sympathy therest of the system—the diseased part aswell as others; so as in many instancesto suspend or put a stop to the diseasedaction that is going on at the time. Thisis called the ciii e by cou7itei, irritfltiolt,and which has been before alluded to.You will perhaps understand this better,it refer you to the stomach, which, inan instant, wiit have its functions sns-

pended, by pain or any other irritation,or even by the communication of an iiti-

expected and interesting piece of intelli-gence, or any other mental emotion ;the appetite immediately ceasing, andthe food often being rejected in conse-quence. Now diseased actions are liableto be influenced in the same way. Titisis the result of that general principletermed sympathy, wijich establishes a

mutual and reciprocal connexion betweenthe different parts ot’ the system, in con-sequence of which, no gscdt. change can

take place in one part, without influen-cing others, in greater or less degree.We are more indebted to the late Mr.

John Hunter, for our knowledge uponthis subject, than to any other person.In fact, all our most powerful means ofcure, are chieny referrible to this principleof counter-irritation. If evacuants, forinstance, are used, the henefit experien-ced from them is not in proportion eitherto the quantity or quality of the mattersdischarged. When we take away blood,it is not because there is too much bloodin the system, or that it is of bad quality ;but it is the change which such remedieseffect in the actions of the system, (thecounter-irritation they occasion,) that in-fluences the diseased part, and that in asecondary way, or by sympathy. Thisenables us to understand another fact,which otherwise appears unintelligibleand contradictory ; namely, that the samedisease may be removed by different, andeven opposite means. The treatment ofburns serves well to illustrate this. Manypractitioners always make cold applica-tions to burns ; while others in preciselythe same circumstances, apply oil of tur-pentine, and other stimulants ; yet eachmode of treatment succeeds. The sameis the case in many other diseases. It is

quite impossible to understand this, with-out referring to the principle of couxter-irritation. A strong impression of anykind, produces a change of action in the

system. If we take, for instance, the caseof rheumatism ; we shall find that somegive opium and ammonia, in large quan-tities, and perhaps blister the parts at thesame time. Others have recourse to

bloodletting, purging, and perhaps vo-miting ; and both modes succeed. Now,although these remedies are widely dif--ferent in their nature, yet you may pert tceive that they agree in one respect ; tlrais, they are all calculated to make ;t pow-erful impression on the system, and there-by to change its mode of acting ; and thechange thus induced may extend itselfto the diseased part, so as to alter the ac-tion going on there ; and the result willoften be, the subsidence of the disease.Upon the principle of counter-irritationall this is intelligible enough ; and we canthus understand, why opposite means ofcure occasionally are found to succeed.There is, however, undoubtedly, a pre-ference due. One mode of treatmentmay be more effectual, or may be leshazardous, than another ; and on this accoiiiit, it is desirable to know which is thebest. -

The one by counter-irritation, that isthe exciting some new or increased ac-

tion in order to put a stop to the diseased

506

action, (upon the principle already men-tioned, that one disease tends to take offanother,) may be applied either to thediseased part itself, or to the’rest of thesystem.The counter-irritation employed, is not

always or necessarily to the degree of

y producing disease ; but merely so as to.

increase the natural actions of the sys-tem ; as in curing slight colds, or febriledisorders by the warm bath, wine whey,or other sudorifics. Sometimes we exciteartificial diseases, as it were, as whenwe employ blisters, emetics, or purga.tives.

In acting upon this principle, we aretotake care that we do not excite a worsedisease than that we are endeavouring tocure; or that we do not (if we shouldfail) leave the patient in a worse situationafterwards. Thus, for example, in treat-ing goiioi-i-licea by injections, we may in-duce hernia humoralis, or cys ti tis, or stric-ture. So again, an emetic exhibited tocure fever, or asthma, may produce apo-plexy, or hernia, if there should be a pre-disposition to those diseases. Further, itis a common (though a questionable)opinion, that if we employ bloodlettingin fever, and fail to cure, the disease witibe rendered more dangerous towards theend, by the weakness thus induced. Sothat in all cases, the occasion ought to besufficient to justify the means. In slightfevers, such as are common in this climate,and which are likely to terminate favour-ably if left to themselves, it is hardlyjustifiable to employ remedies of the kindmentioned, at a period of the diseasewhen their use is equivocal. But in thefevers of hot climates, the most violentmeans are justified by the rapid course

and danger of the disease.Sometimes we act upon the principle ofweukening the system ; as by withholdingthe usual supply of nourishment; or bytaking away blood with this view. Blood.letting has another mode of operation,’besides that of weakening merely. It sospeedily checks inflammation in many.cases, (even while the blood is flowing,)that we can hardly ascribe the good effect.to the weakness induced by it. Somediseases undoubtedly are more disposedto go off if the body be weakened ; as,in the case of active inflammation occur-ring in strong subjects. We may some-

times, therefore, with propriety act.uponthis principle. But in weak subjects, it isnot necessary to do this ; and even theopposite treatment will be often proper.It is better in such cases to endeavour tostrengthen, or at least to increase theactions of the system, and it is on thisaccount, that when indolent diseases

(such as scrofula) occnr in weak subjects,we often allow strong food to be takenand other strengthening means used, andthat with decided advantage. If, inalmost any case, there should be a strongand natural appetite for plain and

ordinary food, I should be seldontinclined to disappoint the patient; be.lieving that the natural appetite is moreto be trusted to than any abstract rea.soning of our own. On this account Igenerally think it right to indulge thenatural appetite, (and such I consider anappetite for plain food to be, where thestomach has not been excited by any va.riety or particular quality of food.) Ina g-reat number of diseases, there is nodisposition to take food ; it is on the con-trary toatfied. When this is thecase, theadministration of food would be injnrioas;for where it is not ta)Ben with appetite, itwill seldom be well digested. Manypractitionners administer food, as if by sodoing, they were directly giving strengthto the system; as if nothing more werewanting, than to make the patient sfat.low toocl, in crder to give him strength.There is no principle more false in theory

nor more injurious in practice, than this.Food cannot give strength, unless it bewell digested and absorbed ; nor, indeed,unless it be taken with appetite. Nowin a great number of diseases, noneofthese circumstances take place; there isneither disposition to take food, nor pow.er either to digest or absorb it. To givefood under such circumstances, is onlygiving fresh cause of irritation to the

system. I have seen strong food admin-istered in fevers, (though loathed at the

time,) under the idea of strengthening thesystem ; but with the effect of aggravat-ing all the symptoms. Fortunately, itis isin these cases generally ejected again,by either voniitixig or diarrhoea. It is not,therefore, in such cases, that food shouldbe administered ; but ouly where diseaseoccurs in subjects previously weak, andnot even then, unless there be a dacidedinclinatioiy for*dt.Sometimes, it may be necessary to sti.

mulate the system, by wine, ammonia, &c.as in chronic inflammation, and in linger.ing fever, towards the end ; even thoughwe thereby increase the general vascularaction for a time ; but this requires to bedone with much caution. Strengtheningthe system is also desirable in long pro’tracted diseases ; but is more difficult toaccomplish than is commonly supposed.In the treatment of diseases, your chief

attention must not be paid to symptom,but rather to their causes, that is, to theactual disease. The removal or relief ofa symptom, is not necessarily curing a

507

disease; 6n the contrary, it is often thecause of aggravation. Pain, for instance,is a symptom of most diseases ; yet itdoes not at all times admit of relief byopium, or other narcotics. Pai7i is oftenthe result of active inflammation; and,generally speaking, in such cases, opiumBlould be highly objectionable. The sameobjection applies. to want of sleep, occa-sioned by active inflammation, especiallyof the brain. If opium be given in suchcases, !nerdy to procure sleep, we mayinjure the patient, by aggravating thedisease. Increased discharges, again, arenot to be considered as diseases, but onlyas the effect of disease. The names

catarrh, and diarrhœa, and some others,would lead one to suppose, that the in-creased discharge was the real disease.If this were the case, we ought to sup-press it as quickly as possible; but thisis in opposition to experience. Such dis-charges are the result of inflammation oithe mucous membrane; it is to this, there-fore, that we should direct our attention,.nd not merely to the suppression of thedischarge. Superficial practitioners con.tinually fall into this error, they are caughtby the most obvious symptoms, and ne-glect further inquiry. If the patientcomplain of pain, they endeavour to re-lieve it by opium. If there be want of

appetite, sickness, &c., they indulge himin the use of stimulants. In chronic in-flammation of the liver, the patient fre-quently complains only of a want of ap-petite, and that the food he takes doesnot sit well on his stomach, but occasionsflatulency, and sometimes spasmodic pains.In such cases, a practitioner is very aptto be misled. He thinks of nothingmore than how to relieve these dys-peptic symptoms, by tonics and stimulants,which, in the end, generally aggravatethe disease. I allude particularly to thisease, because I have often seen slichsymptoms mistaken for the disease, andvery improper treatment resorted to inconsequence. Whole volumes have beenthus written upon dyspepsia, without anyreference to the diseased state of theorgan itself:I In my next lecture, gentlemen, I shallmake a few remarks upon the names ofdiseases. I -,hall show you that medicalnomenclature is very imperfect, and aptto mislead ; instead of giving information,as it ought to do, of the real nature of thedisease.

LECTURESON SOME

PRACTICAL POINTS OF SURGERY

DELIVERED TO THE

Students of the late Borough Dispensar,BY MR. ALCOCK.

LECTURE VII.

On Bandages.Gentlemen,

’ THE duties of surgery are of two kinds,the higher, which relate to the performanceof operations by the knife,-the ordi-nary, which comprise the treatment ofthe accidents and diseases which fromtheir frequency form the greater part ofsurgical practice. ’these common andhumble duties of the profession, thoughtoo often neglected and despised, are notonly more useful to patients afflicted withdisease, but are more nearly allied togood sense, sound judgment, and huma-nity, than " a passion for bloody opera-tions and extraordinary cures."The adaptation of bandages forms a

very important part of the ordinary dutiesof the surgeon, and on his intelligenceand dexterity in the use of the bandagehis success in practice will materially de-pend. Let it not be supposed, in speak-ing of the adaptation and use of banda-ges, that the mere mechanical applicationis all that is required : that soundness ofjudgment which is necessary in the higherdepartment of surgery, is equally so’ toenable the practitioner to determine inwhat cases the bandage may be beneficial,as well as to adapt the use of it to the ex-igencies of each particular case.The remark of Mr. Benjamin Bell res

peetiug the simple operation of blood-letting, may be equally applicable to

bandages ; for it is much more commonto see the greater operations in surgeryskilfully performed than to witness the

ueat and efficient application of a ban-dage.: The uses of the bandage are various,namely, to retain dressings, in the treat-ment of wounds, ulcers, &c. ; to retaindivided parts in contact; to compressblood vessels and restrain haemorrhage ;to suppoit weak parts; to promote thehealing of ulcers ; to promote absorption,or rather to limit deposition ; to destroypreternatural growths; to repress ini’am-mntion; and to support the parts and