Part 1

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Transcriber’s notes:

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

DISSERTATIONS

ON

_INFLAMMATION_.

VOLUME II.

CONTAINING,

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

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

DISSERT. IV.--ON THE SPONGOID INFLAMMATION.

DISSERT. V.--ON THE SCROPHULOUS INFLAMMATION.

DISSERT. VI.--ON THE CANCEROUS INFLAMMATION.

BY JOHN BURNS,

_SURGEON IN GLASGOW_.

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

1800.

DISSERTATIONS

ON

_INFLAMMATION_.

DISSERTATION II.

CONTINUED.

ON

SIMPLE INFLAMMATION,

_And its Consequences_.

_Of the Cure of Inflammation._

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

_Of the Treatment necessary to procure Resolution._

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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