CHAPTER IT.
Of Inflammation.
A COMPLETE acquaintance with this subject is essential to every practitioner of surgery. In the following remarks I shall endeavour to describe its phenomena without at- tempting to investigate the theories which have been formed to explain them.
Inflammation generally commences with an increased sensibility of the part; pain is soon perceived, attended with heat, redness, and tumefaction ; the pulsation of the arteries in the inflamed parts occasions a throbbing, which in some situations is very distressing to the patient, as when the inflammation is seated in one of the fingers. ‘The pain is attributed by Mr. Hunter to a spasm of the vessel, analogous to cramp, tetanus, &c. The tumefaction is owing to the enlarged diameters of the vessels, and to the effusion of serum and coagulating lymph in their in- terstices. ‘Ihe heat of an inflamed part never transcends the heat of the animal at the source of circulation, though the sensation would lead to a contrary belief.*
Inflammation is divided by surgeons into healthy and diseased. By healthy is understood, that which has for its object the restoration of injured parts; by diseased, that in which some morbid peculiarity is superadded to the simple act of inflammation, as in erysipelas, carbun- cle, &c.
The remote causes of healthy or phlegmonous inflam. - mation, are various irritations of a mechanical or chemi- cal nature; wounds, bruises, acrid substances, &. Some-
- The heat and redness are probably owing to the increased rapidity of cir- culation; but in what particular manner is not clearly understood,
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times inflammation appears to arise as a consequence of . febrile diseases, forming what has been called, critical abscess; and in other instances no evident cause ean be assigned, these cases are very improperly considered spontaneous, as they have certainly a remote cause, al- though it be not obvious.
ami he proximate cause of inflammation has been a source of tach theoretical discussion. Mr. Hunter considered it as an iicreased action of the blood-vessels, and this at the present time is a generally received opinion.*
A variety in the exciting cause seems to have no effect in varying the nature of healthy inflammation; though different circumstances of the constitution or part, affect its progress very materially. Strength of constitution ; a vigorous circulation of the blood; and vicinity to the source of circulation, are circumstances highly favoura- ble to its progress, and under opposite circumstances, inflammation frequently terminates unfavourably. The legs, when inflamed, heal much less readily than the su- perior parts of the body. The colour also of an inflamed part, depends on similar circumstances. An inftamed leg
- On this subject see Hunter on the blood, &c. And also Dr. Wilson’s Essays on Febrile Diseases, in which the doctrines of Mr. Hunter are ingeniously, though I think, unsuccessfully opposed. Mr. John Pearson, with his usual accuracy, remarks, “ by proximate cause is to be understood a real physical cause, so inse- parably connected with the disease, that the presence of the one implies the agency of the other: upon the existence and duration of the proximate cause, depends the existence and duration of the disease ; and if the former be changed, there is a correspondent change in the latter.” This is precisely what Dr. Rush means when be declares, in the language of Gaubius, the proximate cause of a disease to be “ipse morbus.” That mere increased action is not the proximate cause of inflammation, can easily be proved. Now since the action of inflamma- tion is altered from healthy action, and since we cannot tell in what this altera- tion consists, it appears to me best to confess, that in the present state of our knowledge, the proximate cause of inflammation is not distinctly known. The degree of action in inflammation varies very greatly; sometimes it is feeble, and sometimes violent. The nature of the altered action of vessels in inflammation, is not more likely to be discovered, than the nature of those actions which in the liver form bile, in the kidneys urine, &c, The mere alternate contraction and ilatation of blood-vessels offer no explanation on any of these subjects.
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is darker than an inflamed arm. When seated in very vascular parts, as skin, cellular membrane, muscle,—it is more rapid in its progress and more favourable in its ter- mination, than in those which are less so; as bone, ten- don, or ligament. As an exception to this remark, how- ever, we must state, that when inflammation attacks vital parts, notwithstanding its great vascularity, it does not progress so favourably as in those of a similar strueture, which are leas essential to life.
Healthy inflammation is always greatest at the part nearest the external surface of the body. When it attacks the socket of a tooth, it affects the external part next the cheek; when it occurs in the vieinity of the rectum, it affects the skin and cellular texture, leaving the intestine sound.
The effects of local inflammations upon the constitu- tion, depend much on their extent and situation. Where they are small, very little inconvenience results; where they are extensive, or seated in vital parts, greater irrita- tion, and considerable fever, are the consequence. In- Hlammation occurring under a tendinous fascia, produces more effect on the constitution than the same degree of inflammatory action in other parts. The fever produced is called symptomatic, and is attended with a quick tense, full pulse, and sizy blood.
Healthy inflammation is always attended by one or more of the following effects—an adhesion of the inflam- ed parts, one to another; the formation of pus, and the removal of portions of the body by the absorbent vessels. The uniform occurrence of these effects induced Mr. John Hunter to describe infiammation in three different stages; the adhesive, suppurative, and ulcerative. The various parts of the body differ in their susceptibility of adhesion, suppuration, and ulceration. The cellular membrane ; the circumscribed cavities, as the abdomen, thorax, tunica vaginalis, very readily form adhesions :——
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Mucous membranes, on the contrary, as the nose, mouth, alimentary canal, the air cells of the lungs, the trachea, &c. very seldom adhere, but readily suppurate. It is generally found that deep seated parts suppurate less readily than superficial: hence, if a musket-ball be lodg- ed at any considerable depth in the body, it excites ad- hesive inflammation, and a cyst forms round it; but if it be lodged nearer the surface, it produces suppuration, an abscess forms, and it is discharged.
‘The symptoms of inflammation which have been des- eribed, exist very evidently in the adhesive stage, but when suppuration is about to commence, they are greatly aggravated; the pain and throbbing become more violent, the heat is augmented, the swelling is more prominent, the redness more intense, and becomes a pale scarlet. Shivering fits come on, the swelling grows softer, and matter is formed, fluctuation may be perceived by exa- mination with the fingers: an immediate abatement of the symptoms now takes place.
If the inflammation be seated in the cellular membrane, the process of ulceration now commences, and the absor- bent vessels remove the solid parts of the body to make room for the lodgment of the pus secreted, and also to pré- pare a way for its escape. In this manner an abscess is formed, which may be defined a circumscribed cavity, eontaining pus. In a common phlegmonous abscess, we have a good example of the three effects of inflammation which have been briefly noticed. At its margin, where © the inflammation is least violent, the inflamed vessels se- crete coagulating lymph, which agglutinates and firmly unites the cells of the cellular texture, circumscribing the cavity, and preventing the escape of the matter into the surrounding parts. Towards the centre of the abscess inflammation has transcended the adhesive stage, and the blood-vessels have relieved themselves by a secretion of pus. This process immediately excites the action of the
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absorbing vessels, which remove the solid matter to form a cavity to contain this pus.
The natural cure of an abscess consists in the absorp- tion of all the solid matter intervening between the pus and the cuticle, by the rupture or bursting of which, an outlet is made for the evacuation of the cavity, after which small projecting vascular spots appear, in every part of it, called granulations, which are formed of the coagu- lating lymph of the blood, which fill up gradually the cavity, and unite one with another, forming solid flesh— a formation of cuticle takes place on the surface, and thus the parts are restored nearly to their pristine state.*
The terminations of inflammation are various. In some instances it terminates by what is termed resolution. In this case all the symptoms gradually subside, and the parts are restored to their natural colour and appearance.
The secretion of pus, already noticed, is to be consi- dered one of the terminations of inflammation. A secre- tion of serum frequently puts a stop to the inflammatory process. The inflammation from cantharides terminates in this way. Instances of this we see also in inflammation in the brain, ending in hydrocephalus. In the thorax, terminating in hydrothorax, &e.
Hemorrhagy has occurred in some cases, and put an immediate stop to inflammation.
Hard tumours occasionally form by the secretion of coagulating lymph in the interstices of parts, and this has been called a termination of inflammation in schirr- hus.
In other instances the violence of action exhausts the vital powers of the inflamed part, and the inflammation terminates in mortification.
- For particular account of the process by which cavities are filled up, I refer to Mr. Hunter, and a paper by Mr. James Moore.
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TREATMENT OF INFLAMMATION. —
In the treatment of inflammation the first object is, to remove if possible the remote causes, if they continue to act. The next is to lessen the inflammatory action. The remedies to effect this latter object are general, or sanstitutional, and local. Those which act on the consti- tutiva are
1st. BLoop-teTtinc. This is a powerful remedy in the treatment of inflammation. The quantity of blood to be drawn, and the frequéhey of its repetition, can only be estimated by the violence of the inflammatory symp- toms. Whenever parts essential to life are inflamed, as the brain, or the contents of the thorax, or abdomen, repeated and copious bleedings become necessary.
2d. Low Drer—Tends not only to diminish the full- ness of the vessels, but also to lessen irritation, and should be strictly enjoined.
3d. Purcine is often necessary in the treatment of
inflammation. But in many cases it is inconvenient on account of the necessity which it occasions for moving the patient, as in cases of fractured bones. Blood-! losing must therefore be substituted.
4th. Certain Neutra, Sasrts—Sulphaie of Soda, Sulphate of Magnesia, Nitrate of Potash, &c. are use- ful, by promoting the seeretions, and are generally com- bined with preparations of antimony; in which case they oceasion nausea, and diminish the action of the blood-vessels.
6th. Rest is essential—The posture of the body should be such as to favour the return of blood from the inflam- ed part. In many local inflammations, posture is of ex- treme importance. The elevation of the feet in cases of inflammation on the lower extremities, is found highly useful.
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Orium may be given to relieve pain in some cases. The local remedies, are, ist. Bleeding from the inflam- ed part by cupping, leeches, and scarifications. Lo- cal blood-letting is most effectual after general bleed- ing has been premised.
2d, Corp AppLicaTions are sometimes of service, but they should only be carried so far as to be pleaw sant to the feelings of the patient. A very common application which is intended to reduce the tempera- ture of inflamed parts, is a solution of sugar of lead, with or without the addition of vinegar. 9j of acetate of lead, to Ziv of water, answers the purpose as well as any other preparation. It is to be applied on linen rags; and, as it soon acquires the temperature of the part, these rags should be often changed.
3d, BiisTERs are, in certain cases, of great use in dimi- nishing inflammation. They must be applied directly over the inflamed part; and in many cases, produce a speedy cure. ‘
All these remedies tend, by diminishing the violence of inflammation in its adhesive stage, to prevent suppura- tion, which is generally to be attempted: but cases oc- cur in which this event is desirable, and others in which it is inevitable. The best application in such cases is a soft poultice of bread and milk, with the addition of a little sweet oil, or fresh lard; or ground linseed and water.
‘When suppuration has taken place, and a fluctuation of matter can be perceived, if it be not soon evacuated by absorption, it becomes necessary to expedite the cure by an artificial opening.
Abscesses should be opened early, when situated near the larger cavities of the body, as the thorax or abdo- men, as instances have occurred in which they have dis- charged their contents into these cavities, occasioning fatal consequences. In paropychia, or other very pain-
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fal collections of matter, especially where the pus is con- fined under a tendinous fascia, an early opening should be made ;—when situated near large joints ;—when they im- pede respiration or deglutition ;—when they oceasion ner- vous fever, or other constitutional affections, they should be opened early. The best application after the cavity efan abscess is evacuated is a soft linseed or bread and milk‘ poultice.*
‘There are two ways of opening abscesses ; by inei-
sion and caustic. Bhe lancet is to be preferred when- ever we can choose; if the patient, howeves;.from great fear of a cutting instrument obstinately refuses to submit, caustic may be substituted—a piece of caustic vegetable alkali rubbed over the part eight or ten minutes, will oc- casion a slough, and give vent to the pus.
The properties of pus have been well described by Mr. Home. It is a light straw-coloured fluid of the consist- ence of cream, composed of globules swimming in a fluid, which fluid is coagulable by muriate of ammonia—a property which distinguishes pus from all other animal fluids. Healthy pus is perfectly bland, free from all acrimony. It is heavier than water, and sinks in it with- out mixing. Pure pus does not readily putrefy; but when mixed with blood or extraneous matter it ferments and becomes putrid, acquiring a fetid smell, and is now acrid and irritating. It is evidently a secreted fluid poured out by the inflamed vessels which assume the na. - ture of a gland.
- A very ready mode of preparing the linseed poultice, is to mix the linseed meal with warm water until it acquires a proper consistence. If the iinseed meal be not at hand, itjs easily prepared by passing common flax seed through acoffee mil.
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