R95-1i 3^i-*;;:;is# f; ;;p i -j. PJ» |g«B NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Serrice **> r-v .*. «S, .. •* s* \ AN INAUGURAL DISSERTATION INFLAMMATION. '0K/1 7 ing sleep, and that no accumulation of the vital principle can take place in consequence of their action being diminished; therefore no such accumu- lations occur in syncope, haemorrhage, or exposure to low temperatures. It must be observed before quitting this subject, that all the contractile fibres, during life, are liable to exhibit, at different times, different degrees of contraction, or modes of existence, each of which gives a peculiar density to the solids, (for the degree of density is in proportion to the degree of contrac- tion) and is marked by peculiar degrees of pleasure- able or painful sensation. The first of these states to be noticed is one which often obtains in disease, when, from the small quantity of blood, or weakened action of the arteries, the secretion and expenditure of the vital principle is very small. The greater degrees of this state exhibit the most inconsiderable quantity of action compatible with life, and are distinguished by the words, " loss of tone, or laxity of fibre." The second state to be marked is one usually ex- hibited by the fibres in health, and commonly dis- tinguished by the words, " tone, or tonic state;" which is a moderate degree of contraction, de- On Inflammation. 15 pendant on a considerable secretion and expendi- ture of the vital principle. A third state is that exhibited by the involuntary muscles, in the performance of their healthy ranc- tibns, as the heart and arteries in the circulation of the blood; and by the voluntary muscles in* their or- dinary motions. In this state the contractions are so great as to expend the vital principle faster than it is ordinarily secreted; therefore frequent relaxa- tions become necessary. A fourth state is that exhibited by the contractile fibres in spasm. The violence of the contractions in this state chiefly depends on the intensity of the exciting cause, and expends much of the vital principle ; hence relaxations alternate with, or soon follow such contractions. Now, as the power of the exciting causes of fibrous contractions is diminished in proportion as the density of the solids is increased, it will be easily seen why spasm so often occurs in atony, and why violent contractions, once excited, (whether of the muscular or nervous fibres, as in spasm and reverie) are not affected by ordinary exciting powers. If the smaller degrees of atony exist, and, at the same time, a paucity of exciting powers, ennui will be the consequence. The second and third states described above are attended with pleasurable, the fourth with painful sensations. ( 16 ) INFLAMMATION. TUMOUR and redness of any part constitute? inflammation. I am aware that Cullen, Bell* and others, have added to the above symptoms those of pain and increased heat; but as these do not always occur, arid when they do, are merely accidental, I cannot admit them in the general de- finition of the disease. However, as pain and in- creased heat have so often attended inflammation as to have contributed largely towards obscuring the real character of that disease^ I shall pay thern a more particular attention. Inflammation takes place in any part of the body, if the red vessels of such part are by any means deprived of a portion of their contractile energy, and their powers of action are thereby reduced below the similar powers of the system generally. This condition, it must be observed, is absolutely necessary to the production of inflammation; for if all the vessels in the body were, at the same time, and to the same extent, deprived of their contractile energy, though much atony might fol- low, inflammation could not; for the quantity of action being equal throughout the whole, the dis- tribution of the blood would also be equal: and inflammation cannot exist in all the vessels of the body at the same time, for the quantity of blood is insufficient to produce the necessary distention. On Inflammation. n Inflammation then consists in a loss of tone, and consequent weakened action of the vessels diseased. Loss of tone of the muscular fibres is alvfl^s at- tended with diminished secretion and excretion, consequently diminished irritability of the nervous fibres with diminished sensibility; therefore, dimi- nished secretion, excretion, irritability, and sensibi- lity, are the consequences of inflammation to the part diseased. Although inflammation is, in itself, weakened action, as described above, it is a direct stimulant power to every other part of the system. Hence the consequences to the general system will vary according to the extent of the disease and the part affected. When inflammation comes on in the neighbourhood of many nervous fibres, as in the vessels of the skin, cellular membrane, or volun- tary muscles, pain will attend in proportion to the tumefaction; because the greater the tumefaction, the greater will be the pressure; consequently the greater the stimulant power of the disease on the surrounding parts. The pain, in this instance, is not to be referred to the nerves immediately in- volved in the disease; for these, notwithstanding they are operated upon by a powerful exciting cause, have their sensibility so much diminished, in consi- derable degrees of inflammation, as to be hardly excitable; but to the nerves immediately surround- ing the diseased part, which have their sensibility increased in consequence of such stimulation. In some cases, the pain is removed still farther from c 18 On Inflammation. the seat of the disease; as in inflammation of the liver, with pain in the shoulder, or in the blad- der, 4P at the extremity of the urethra. The increased heat, which often attends inflammations of these parts, is to be referred, in like manner, to the pressed upon and highly excited arteries, in the neighbourhood of the disease. And that the heat, after being secreted by these vessels, should accumulate on the diseased part, is not unaccount- able, seeing the secretion of the perspirable matter is suspended, or very much diminished, which is known in ordinary Gases to carry off a large portion of the sensible caloric. If parts, with few nerves, as the liver, lungs, &c. become inflamed, the pain will be proportionably small; if without nerves, as the pleura, tendons, &c. pain will be altogether absent.* Inflammations, while confined to a point,- and not very painful, by their gentle stimulant power often invigorate weak constitutions: hence the good effects of setons, issues, blisters, &c. but when much extended, whether very painful or not, their stimulant power becomes so much increased as to excite a quantity of action incompatible with health, and one therefore which cannot be conti- nued, A very great quantity of action seems to be incompatible with life and health; for this rea- son, that secretion being in proportion to the quan- tity of action, the blood becomes rapidly diminish- * See the Experiments of Mr. Monro. On Inflammation. ig «d, removing thereby not only an exciting cause of vascular action, but diminishing the secretion of the vital principle; which, under certain circum- stances, becomes both the remote and immediate causes. Every organ entering into the composition of animal bodies, must be considered in two points of view; first, as performing its own functions as an individual; secondly, from its connection with, and action upon the other parts, as a stimulant power, exciting every other organ to increased action. Some organs, therefore, as the brain, stomach, intestines, and lungs, from the great quantity of action which they perform in them- selves, and excite throughout the body, have been called centres of association to the motions gene- rally. Now, notwithstanding inflammation is a stimulant power, and as such generally increases the action of every part not immediately involved in the disease, yet being in itelf diminished action, if it affects any of the organs above named, the quantity of action of the whole system will be thereby diminished; for the body sustains a greater loss of stimulant power from any one of its capital organs becoming inflamed, and its motions thereby suspended, than it gains from the inflammation itself. Hence weak pulse, and frequently dimi- nished heat, in phrenitis (if such disease exists)* gastritis, enteritis, and some cases of peripneumo- nia. In setting down phrenitis, or inflammation of the 30 On Ittflammdtion. brain, as a disease of general decreased action, I have differed materially from Cohen, as may be seen by turning to his history of that disease. But I am not the first who have ventured to question the existence of a perfect case of such inflamma- tion, upon the ground that life would be discon- tinued long before it became universal. Some partial cases of inflammation of the brain I have seen in the latter stages of malignant fevers; but they have been in every instance marked by stupor and loss of voluntary motion. I have also seen some cases of disease where the brain appeared to be highly excited from inflammation of the neigh- bouring parts, These cases assumed the character pf Ctjllen's phrenitis. From not discovering or attending exactly to the seat of inflammation, physicians have some- times been led into other errors of opinion, of the nature of the above, For instance, Dr. Darwin asserts that the liver inflamed performs more secre- tion than in health. The principle I have laid down will, however, explain all such mistakes. Physi- cians have also misled themselves and others, with respect to the nature of inflammation, by gathering symptoms for it from parts in which it did not exist. For instance, John Hunter says, " The act of inflammation would appear to be an in^ creased action of the vessels. Inflammation in a part is not only an action of the smaller vessels in the part itself, but in the larger vessels leading to it. This is proved by a whitlow taking place on On Inflammation. %\ the end of a finger; for although inflammation itself shall be confined to the end of a finger, and the inflammatory sensation or throbbing be situ- ated in this part, yet we can feel by our hands, when we grasp the finger, a strong pulsation in the two arteries leading to the" inflamed part; while no such pulsation can be felt in the other fingers."* But Dr. Hunter might have observed, that while there was no evidence of increased action in the vessels of the diseased part, these arteries of which he has spoken were not themselves actually diseased, but in the neighbourhood of the disease, and there- fore stimulated by it; and that the increased action of highly excited, but healthy vessels, could not be admitted as evidence of increased action of vessels in other situations, and under other circum- stances: and although no such pulsation existed in the arteries of the other fingers, yet the action of these, as well as of every other artery in the body, was increased in proportion to the violence and extent of, and the distance from the diseased part. Inflammation is most easily excited in weak and delicate habits, and therefore occurs oftenest in such ; it is also liable to accompany other diseases of debility, as dropsy, &c. as was well observed by Dr. RusH.f Nor need those who know that in all cases of debility every cause of inflammation always * See Hunter on Inflammation. t See Medical Inquiries. 22 On Inflammation. exists, except the proximate, be alarmed at the fre- quent occurrence of that also. Hence the opinion advanced by Dr. Mease, ought not to startle any one, unless correct opinions among medical gen- tlemen be allowed to startle on account of their rarity.* It will be observed, that I have often used the word secretion, in the course of this dissertation 5 and have endeavoured to show that it was dimi- nished in inflammation, as well as in every state of vascular debility; it therefore becomes proper to ex- plain what I mean by that term. Secretion may be defined an action of the vessels, whereby the blood is decompounded, and new compounds formed, for the peculiar and healthful purposes of the animal. I am aware, that if any fluid secreted in health should be found to correspond exactly in all its pro- perties to some portion of the blood, it would form an objection to this definition; but until such1 fluid be pointed out, I must continue to believe it accurate. If, however, a great degree of relaxation at the extremities of the vessels should suffer some parts of the blood, from their greater tenuity, to run off unchanged; this could not be termed secretion, with any more propriety than we should call ordi- nary haemorrhage by that appellation. Therefore, those discharges which often obtain from inflamed surfaces, as well as those which are made beneath • See Med. Rep. vol. i. p. 149. On Inflammation. 2S the skin, into the cellular membrane, &c. in cases of extreme debility, as the vibices of malignant fevers, and the blisterings frequently preceding gangrene, are not to be termed secretions, as they are not the result of vascular action, but suffered to take place merely through debility; and the different dis-« charges in these cases mark the degree of debility very exactly. Thus, where the serum only, which is the finest portion of the blood, is discharged, the most moderate degree of inflammation exists, and one which may continue a long time under the same appearances; as in fistulous ulcers, gonorrhoea* &c. If, however, the degree of inflammation is by any means a little increased, a second portion of the hlood will also be poured out with the serum, and the condition of the part thereby materially chang- ed ; manifesting all the phenomena of adhesive in- flammations, as in the healing of wounds, ulcers, &c. for this second portion, or the coagulating lymph, is the fluid of which the animal solids are formed, and to which, whether in the vessels or not, life is pre-eminently attached. If the degree of inflammation is carried still higher, a state of debility is induced incompatible with the life of the vessels; therefore spreading of the ulcers, or morti- flcation of the part, must follow. ( 24 ) CAUSES OF INFLAMMATION. A quantity of action so great as to expend the vital principle faster than it can be supplied, id the most frequent remote cause of inflammationt Those stimulant powers which eXcite this great quantity of action, are the pre-femote causes. The subduction of the stimulant powers* as in the ex* posure of a part to cold, and the consequent loss of action, are frequently, too, the remote causes of this disease. In short, whatever induces debility imme- diately, may cause inflammation remotely. Debility, then, by whatever means induced, stands next in order to be considered as a cause of inflam- mation : it, however, from its apparently passive na- ture, cannot be well called exciting or disposing, and having no other appellation at hand, I shall leave it to the reader to name. The proximate cause of inflammation is pointed out by the condition laid down above; which was, that the vessels of the general system should pos- sess sufficient power to push on their contents, and distend such vessels as were unable, through de- bility, to rid themselves of such contents after re- ceiving them. For it will be easily seen, and may be seen every day, that the remote cause of inflammation has acted, and ended in debility; yet the disease does not appear, unless the debilitated vessels become over-distended with red blood: the On Inflammation. 25 power, therefore, which distends these vessels is the proximate cause, and this power is the activity of the other parts of the system. But in order to ihe distention taking place, it is not necessary that t\e healthy parts should act with unusual energy, oi that blood be derived to the weakened part in geater quantity than usual; for if it is derived at al, and retained in greater proportion, the disease mist necessarily take place. By way of illustration to my general doctrine, I shall set down the causes of inflammation in the order of their occurrence, and the production of the disease in question. These I expect to find happily arranged to my purpose, in the case of inflammation spreading from a point to the surrounding parts. Nor can the tak- ing of a case of inflammation, which is to be con- sidered as having existed for some time, form any objection to the statement, because, while the dis- ease continues to spread, all the causes are pre- sumed to be in full operation. Now, the inflamed point which stimulates the surrounding parts is the pre-remote cause; the quantity of action which is excited by the pre-remote, and ends in indirect de- bility, is the remote cause: in consequence of this debility, thus induced, the vessels suffer themselves to be over-distended by the proximate cause, and the disease appears. That redness and tumefaction which often attend the exposure of a part to cold, appear to be a perfect case of inflammation, and throw much light on the nature and production of that disease. p ( 26 ) ;'*• CURE. r- The cure of inflammation may be attempted on several grounds: first, by the removal of tie proximate cause, as in bleeding, purging, 8iC: secondly, by diminishing the power of the remote cause, as in the application of cold and other se- datives to the part affected: thirdly, by removing the debility of the diseased vessels, by the applica- tion of astringents and stimulants to them. THE ENU. 3.70 c/