jiis ■:i?.;i;;'^: i^ if !:Mi;i!:;:':^'ii;a-;ii:.;:; iawwS feiii'.jiiiiiW NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service TO ASCERTAIN THE CAUSE •i'.'* OF THE EXTENSIVE INFLAMMATION, WHICH ATTACKS WOUNDED CAVITIES AND THEIR CONTENTS. BY JAMES COCKE, OF VIRGINIA. Philadelphia: FROM THE PRESS OF THE LATE R. AITKEN, BY JANE AITKEN, No. 20, NORTH THIRD STREET. 1804. ^i%) 7 AN INAGURAL ESSAY, FOR THE DEGREE OF DOCTOR OF MEDICINE; SUBMITTED TO THE EXAMINATION OF THE REVEREND JOHN ANDREWS, D. D. PROVOST, (PRO TEMPORE ;) THE TRUSTEES AND MEDICAL PROFESSORS OF THE UNIVERSITY OF PENNSYLVANIA. ON THE 5th DAY OF JUNE, 1804. BENJAMIN RUSH, M. D. Professor of the Institutes and Practice of Medicine in the University of Pennsylvania, Wc. DEAR SIR, IMPRESSED with the highest respect for your professional talents, I claim, as your pupil, the privilege of dedicating to you, my Inagu- ral Dissertation. I am, however, more strongly impelled to it, by a knowledge of the many amiable and esti- mable qualities, which distinguish you, in your private and domestic relations; and which se- cure the affections of all, who have the pleasure of a constant intercourse with you. I should, indeed, be insensible, sir, if I could leave this institution, without making the most grateful acknowledgements of the singular ad- vantages which you have afforded me, as my public teaciier, my private preceptor and my faithful friend; the recollection of which, will ever be pleasing to, Your much obliged, Pupil and Friend, May 19th, 1804. JAMES COCKE. ASTLEY P. COOPER, Esq. f. R. S. Surgeon of Guys Hospital, Lecturer on Surgery, and adjunct teacher of Anatomy, at St. Tho- mas' Hospital, London, £Cc. IF it were possible for me to request it, your politeness, dear sir, would insure me per- mission, to prefix your name to this Essay. I think it fair, to avail myself of your protection, as one of my teachers in surgery; And parti- cularly on this subject, to which my attention was attracted, by your practice and lectures. Should the doctrine which I advocate, be just, and the practice which it suggests, be correct; I do not know any person to whose candour and liberality, and zeal for the improvementof surge- ry, I would sooner commit its defence, than to yours; as I know you to be incapable, of reject- ing any opinion, simply because it is first ad- vanced at a foreign University, and defended by a student of Medicine. Allow me now, sir, to return you my thanks for the uniform civility, and kind attention with which you favored me, during my residence in London, and to assure you of the high respect with which I am, Your Obliged Friend, and Most Obedient Servant, JAMES COCKE. May, 19th, 1804. ..... ■ I ■ gg=* AN INAUGURAL ESSAY, #7\ j IN deciding on a subject for a dissertation, much difficulty presented The great variety of diseases, which are interesting to physicians, have already attracted the attention, and exhausted the ingenuity, of other can- didates for medical degrees. Independently of their pro- ductions, all diseases have been treated of, by medical writers of the greatest note, on whose descriptions and modes of practice, I could not have flattered myself, with the hope of making any improvement. I have been induced to institute this enquiry, into the cause of the extensive inflammation which takes place on wounded cavities, not only, from a consideration of the contrariety of opinions, which prevails among surgeons, on this subject, but by a hope, that I might bring into view, a source of this inflammation, which I think the true one, although it has heretofore escaped notice. In the progress of this essay, I have been obliged to take a short review of the doctrines of the principal writers, who have touched on this subject. I hope I have succeeded in quoting their opinions fairly ; and that I have in no in- stance, forgotten the respect, which is due to those, who have laboured to enlighcen, and alleviate the miseries of, mankind. The greater danger, of wounds penetrating into the cavities of the body, than of wounds of equal extent in other muscular or membranous parts, must have been no- ticed by the earliest practitioners of surgery. But, al- B 10 though the fact has been so long known, and admitted, by all writers who have mentioned the subject, no satisfactory explanation of it, has yet been given. An occurrence so frequent, so obvious, and so inter- esting, as the violent inflammation, which takes place on wounded cavities and on parts contained in them, could not fail to attract the attention of pathologists, and it has been attributed, by those of the highest credit, to different cau- ses. None of their theories have, however, been so sup- ported, as to gain general credence, and every surgeon embraces that, to which accident, prejudice or reflection has inclined him. I shall not attempt to detail, all the hypotheses which have been advanced by authors, with a view of explaining it. Some of them, from the high authority by which they have been introduced, atid from the ability, by which they have been urged; demand particular attention. Howe- ver opposite and contradictory the opinions of writers have been, as to the cause of the dangerous symptoms which supervene on a wounded cavity no one has questioned the importance of ascertaining it, as it is evident that a dis- covery of it, would lead us directly to the most rational way of preventing them. It appears to have been the opinion, generally received, from the most remote period of medical history, that at- mospheric air has an injurious effect, when admitted into contact with parts, which are naturally defended from it. The opinion was simply announced, and as inflammation was always extensive, when any cavity was opened, and a communication with the atmosphere established; the air being the only foreign matter which could possibly insinuate itself, it seemed natural to conclude, that it was the offend- ing cause; from this circumstance, I presume, the doctrine of the deleterious properties of air took its rise, and this theory the most universally acknowledged, appears for a long time to have been deemed incontestable, although in- tirely unsupported, except by a slender probability and the 11 respectability of its advocates; nor do I find that any wri- ter had ventured to oppose it, untill within a few years. This ancient and common opinion was adopted, extend- ed and inculcated by Dr. Monro, who enters largely into the investigation, " Of the cause of the dangerous inflam- mation which generally follows the wound of a shut sac, and of the manner of preventing it."* Influenced, by a consideration of the difference between simple and compound fractures and dislocations, by the re- sults of a number of experiments which this author made.j and by the issue of some cases, in which air was supposed to have had access to the cavities of joints, he concludes that the inflammation, which takes place on wounded cavi- ties, as well as that following some of the principal opera- tions in surgery, is chiefly owing to the admission of air, to which he appears to attribute highly stimulating powers. That this very respectable writer was deceived, by taking only a superficial view of the subject, may, I think, be easily shewn. In the common accident of a fracture of the ribs, with a laceration of the lungs, the cavity of the chest is filled with air, from whence, it escapes into the cellular substance on the thorax, and is thence diffused through the cellular texture over the whole body; in these cases, unless the integuments are wounded and a communi- cation made externally, no great inflammation is the con- sequence ; although air in abundance is applied to the cavity of a shut sac, to a surface unaccustomed to its ac"lion, and on which it is said to produce highly stimulating effects: In what way has it here been rendered inert ? and, why is it not uniformly followed by its supposed ordinary conse- quence ? Some experiments have been made by Mr. Astley Cooper, to decide, whether air is stimulating to internal surfaces. I do not know the particular manner in which they were performed, but from the known accuracy and ability of that gentleman, I have no doubt, of their having been conducted fairly, and of their having borne strongly * Monro's Description of all the Bursse Mucosae, of the hum»n body, p. 39. 12 and directly on the point, which he wished to ascertain: The result was, a conviction that air does not stimulate. I am unable to determine, whether the pressure on the contents of the abdomen, by the diaphragm and abdominal muscles, is so uniform, as to exclude the air entirely from that cavity when wounded, as has been asserted by Mr. John Bell; but as that cavity contains the intestines, filled frequently with flatus only, and composed of thin and yielding coats, it seems equally probable that air should get access to this cavity, as to that of the chest, filled with the lungs; which are well known, to be some times oppressed by air, entering through wounds of the breast. As a proof, that the cavity of the abdomen is'replete with its contents, Mr. Bell observes, that hernia is frequently produced, by a blow upon the belly or by any sudden exertion.* That either of these, may be the cause of hernia, I am well aware, as a blow on the abdomen, may be given in such a way, as to make the bowels press violently on all sides; and if there is a weak part, it will yield, and some of the contents will be forced out of the cavity. On the same principle, a bladder, nearly filled with water, will burst, when forcibly stricken. That the abdominal muscles are capable of contracting so violently, as strongly to compress the bowels and to produce a rupture, cannot be disputed; but it is not more correct, to suppose the muscles of that part to be in their common state, thus contracted; than it would be to calculate that the gastrocnemii muscles are always a£ling with great force on the Tendo-Achillis, because they sometimes act so powerfully, as to rupture it. If this pressure were so extreme and unremitting, the bowels would not be able to perform their functions; and the large and undefended vessels, especially the veins, would have their circulation arrested. One great source of alarm to Mr Bell, is certainly ideal; he apprehends that the blood vessels of the abdomen would burst, if not supported, by pressure on the surrounding bowels. That these vessels can bear unaided, the weight and momentum of the blood, * Bells Discourses on wounds, part II. p. 71. 13 is fully proven by their sustaining no damage, after child- birth or the discharge of large collections of water in abdo- minal dropsies. In neither of which cases can the flaccid parietes of the abdomen be supposed to have any influence on them. THE doctrine of air stimulating internal surfaces, du- ring so long a period almost universally acknowledged, has been subjected to a close and severe examination by some late writers. As just and weighty objections could be adduced against it, it has been rejected, and attempts made by Mr. Hunter, Mr. Abernethy and Mr. John Bell each to substitute his own in the place of it. The genius and celebrity of Mr. Hunter, as might have been expected, have engaged many of the most respectable surgeons of the present time, in favour of his opinion. The high respect which I entertain for the talents of these gentlemen, some of whom I have been accustomed to view, with that partial regard, which results from a sense of bene- fits conferred, of which I hold instruction to be the greatest; and the veneration which I feel for the character of Mr. Hunter, induce me to hesitate when I think of attempting an examination of his theory, and of pointing out any mis- take, into which, from the multiplicity of subjects engaging his attention, arid the vast extent and importance of his disco- veries and improvements in physiology and surgery, he may have fallen, in some points of inferior moment. Nor should I undertake it, if I were not compelled to write, and at the same time fully persuaded of the inaccuracy of his doctrine on the subject of this paper. " In many cases of the emphysema, where the air is diffused over the whole body," says Mr. Hunter, " we have no such effect, (as inflammation) and this air not the purest, excepting there is produced an exposure or imperfection of some internal surface for this air to make its escape by, and then this part inflames. Nay, as a stronger proof, and of 14 the same kind with the former, that it is not the admission of air, which makes parts fall into inflammation, we find that the cells in the soft parts of birds, and many of the cells and canals of the bones of the same tribe of animals, which communicate with the lungs, and at all times have more or less air in them, never inflame; but if these cells are ex- posed in an unnatural way, by being wounded, &c. then the stimulus of imperfection, is given, and the cells inflame, and unite if allowed; but if prevented, they then suppurate, granulate &c."* These are the chief grounds, on which Mr. Hunter has introduced the new, and to me, incomprehensible doc- trine of the " stimulus of imperfection;" which appears to have been assumed, without the semblance ot proof, or any arguments shewing even the probability of the existence of any capacity in the animal economy to give it. It is, indeed, very certain that all wounded cavities are imperfect, and this being a necessary and unavoidable circumstance and uniformly attending; as it applies to every case, is, with perhaps something more of the appearance of truth, char- ged with the consequent inflammation, than air, which had before been suspected. Mr. Hunter is not explicit as to the source of the sti- mulus of imperfection; nor am I certain, whether he intend- ed to convey the idea, that it is given by an intelligent a- gent, but from the manner in which he speaks, he must have viewed it, as arising from some power capable of de- ciding when such a stimulus is necessary, directing its efforts to the benefit of the system and instituting such ac- tions as are necessary to restore parts that are injured. If this doctrine were in every other respect satisfactory, the introduction of this single term, which I am unable to familiarize to myself, by the substitution of any simple ex- pressions, would be sufficient cause with me, for its total rejection ; as well might we admit, the volition of nonen- tity, in Metaphysicks. But, I am still more unwilling to * Hunter on Blood, vol. II. p. 98. 15 admit Mr, Hunter's terms, from a recollection of the ex- tensive injury, which science has heretofore sustained from theories, requiring the aid of imaginary intelligen- cies, to explain the operations of the human body, both in health and disease. They paralized investigation, and appeared to render superfluous, the researches of the phy- siologist and pathologist, farther, than to trace causes to that point, at which, these agents might be supposed to commence their action. Whether the cells in the soft part of birds, and the cells and canals of their bones are liable to become infla- med, from the alternation of heat and cold, I am not cer- tain. But, as other animals beside man, particularly the horse, are subject to catarrhal affections, by passing sudden- ly from a low, to a high temperature of air, I think it en- tirely probable that these cells and canals, which are parts of the respiratory apparatus of birds, may also under si- milar circumstances be inflamed. Other considerations however, have weight with me, as they shew the inadequacy of this theory. Emphysema, the very affection, on which, Mr. Hunter has in a consi- derable degree, rested his conclusions, against the supposed effect of air in inducing inflammation, is intirely apposite to my purpose and contributes largely to disprove his doc- trine. It shews that inflammation does not always occur to any considerable degree, from a cavity being rendered im- perfect, and remaining so for sometime; which frequently happens, when, from a fracture of the ribs, one lung and both sides of the pleura are torn, and a communication with the external air remains for several days; and in such cases it cannot be denied that the cavity is imperfect; both by a communication through the lung, trachea and mouth; and also, by a laceration of the pleura costalis and intercostal muscles, giving passage to the air, into the cel- lular membrane on the trunk. Whence it is diiTused over the whole body, which latter circumstance alone, seems sufficient to warrant the cavity being called imperfect. 16 When a wound is made into any of the cavities of the body, the abdomen for instance, every part of that cavity, as the integrity of the whole has been affected, should, ac- cording to the doctrine of Mr. Hunter, feel the stimulus of imperfection, and take on that action, which this sti- mulus is suited to excite. But generally, a portion of in- testine, is protruded through the wound, and in a short time we perceive the peritoneum, which covers this piece of intestine, becoming more vascular, and incipient inflam- mation taking place on it; while every other part of that cavity is entirely free from inflammation. Surely no good reason has been assigned, why a general cause should pro- duce an effect so partial, nor does any explanation by the author of this doctrine occur to me, unless the stimulus of necessity is brought into action, which may be said, to induce the inflammation, with the intention of rendering the cavity perfect, by producing an adhesion between the lips of the wound and the surface of the protruded bowel. But as the admission of this extraordinary agency, would be perfectly gratuitous; I think it proper, to adopt a mode of accounting for these occurrences, which seems to be founded on a firmer basis. The utility of the inflammation which takes place on the surfaces of wounded cavities, will not, I believe, be questioned, nor will it be affected if shewn to arise from a law which pervades all animated nature, and not to be under the guidance of an intelligent principle or anima me- dica. THE infl -mmation, which generally follows the evacuation of matter from an abscess, and which, uniformly occurs in cavities that are laid open, could not escape the observation of Mr. Abernethy, who, ever close in his in- vestigations and cautious in his conclusions, found it neces- sary, to abandon the theories which had been advanced by others, and to propose a more plausible one, which, attri- 17 butes the inflammation to the frequent renewal and the long tontinued application of air, to a surface unaccustomed to it. To this opinion of Mr. Abernethy, however, an objec- tion presents itself. Although under ordinary circumstan- ces his explanation may, and I believe will, be found to be literally true, yet, I am certain that his intention was to in- culcate the doctrine, that air, when frequently renewed and long continued, acts on internal surfaces as a stimulus; which meaning, may be fairly deduced from his words; " a constant renewal of air is permitted, and the applica- " tion of a matter so unusual to these surfaces, I am incli- " ned to believe does harm."* Which doctrine, I think will not prove to be correct, as I am led to believe from a consideration of the mildness and pleasantness of air, when applied under certain circumstances, either to the internal or external surfaces for any length of time, and from an assurance, on high authority, that it is not stimulating to the animal fibre. L........... ' J OF the various theories which have been proposed on this subject none has been more confidently advanced, than that of Mr. John Bell of Edinburgh. He assures us, that the " inflammation running so quickly round all the sur- faces of shut sacs, wherever they happen to be wounded, proceeds altogether from another cause, (than air) simple and plain to the last degree. For, in the wound of any shut cavity where the parts do not adhere, the inflammation spreads and runs its course, by a law of the animal econo- my, which we explain very ill, when we call adhesion the adhesive stage of inflammation, representing, as the first stage of a most dangerous disease, that adhesion which is a natural and healthy action, the most natural in all the system and the farthest from disease."f * Abernethy's Essay on Lumbar abscess p. 55. f Bells Discourses on Wounds, Part II. p. 93. IS Simple and plain, as the cause of the rapid prdgreii of inflammation in cavities, appeared to this ingenious surge- on, it is certainly to be regreted that he has not dispelled the darkness which to the view of most others, still rests upon this point. The ideas of Mr. Bell, as to the cause of the inflamma- tion, are more clear and accessible. " It is plain" he says, " that inflammation, or the absence of it, arises not from the presence or absence of air, but from the length of the incision, thefe is no inflammation where the wound is small, though it is made on account of confined air ; there is inflammation where the incisions are large, though they are made with the intention and also with the effect of letting loose the confined air."* I am entitled by a variety of circumstances to deny, that the membranes lining cavities, are liable to become in- flamed from slight mechanical injuries. In a number of experiments performed by Dr. Monro; he found that the inflammation was never in proportion to the size of the wounds made into the cavities of animals, but that it cor- responded, with the time and manner of the exposure of the bowels to the air.f The capability of membranes lining the cavities of joints to bear violence without great inflammation, is shewn in all cases of dislocations, where the capsular liga- ments and consequently the lining membranes are lacerated. Similar hardiness is evinced by the pleura, which must frequently be considerably torn, by the rough ends of frac- tured ribs, and yet we see persons in whom it has happen- ed, recovering without any of the symptoms of thoracic inflammation. Inflammation from local irritation is generally pro- portioned to the extent of the injury, which is certainly not the case in wounds of cavities, the lining membranes of which, are sometimes extensively lacerated and no inflam- * Bells Discourses, Part II. p. 90. f Description of the Burss Mucosa, p. 45, 19 matron follows, while in other cases, the most alarming in- flammation supervenes on a cavity, wounded only by a small puncture. Irritation from wounds, on which Mr. Bell lays so much stress in that discourse, in which he treats of inflammation of cavities, will not explain, why inflam- mation immediately takes place, on any portion of intes- tines, protruded through a wound of the abdomen. It furely will not be faid, that the irritation or inflammation of the wound, has been communicated to the bowels by Mr. Bell's sort of contagion, and thus propagated over the whole of the peritoneum covering them. If the inflammation of cavities were caused by the irri- tation of wounds, it would be expected to spread gradu- ally from the wounds to th^ nearest portion of the lining membrane, and in a regular way to travel over the whole surface, which does not take place. But if any of the contents of a cavity are expofed, they immediately in- flame over their whole surface, leaving in a sound state all that extent of lining membrane which intervenes, from the wound to the part protruded. In some cases, the in- flammation of the intestines cannot be supposed to have the slightest dependence on, or the most remote connection with, the irritation of the wound. Of which, two experiments, made by Mr. Hunter with other views, furnifh striking proofs. In one of these experiments, the surface of the tes- ticle of a young ram, being expofed, became almost imme- diately more vascular, and in an hour or two difcharged mat- ter, different from that which is generally found on its surface. In the other, the cavity of the abdomen of a dog was laid open by an incifion of several inches long; in five minutes, the increafed adion of the veffels of the cavity, had altered, and augmented the quantity of, the lubricating matter; in fifteen minutes the surface was apparently more vascular, and the appearance of the secretion still more changed. " The spleen" (and I suppose the other viscera) "had its surface excessively red, from the increased numberof small vessels carrying red blood. From these appearances" 20 says Mr. Hunter, " the fluid which lubricates the peritone- um seems to undergo changes, in consequence of exposure, and at last, when inflammation takes place, to have coagu- lating lymph substituted for it."* Before we can suppose this instantaneous effect to be produced by the irritation of the wound, it will be necessa- ry to conceive, that its velocity is nearly equal to that of the electrick fluid, and to attribute to it a power more extraordi- nary, that of inducing inflammation on one part of a surface, passing over that which from its continuity should next be affected, and seizing on another, and more distant part. The imtation, from the puncture of a lancet, or even an incision, cannot be compared with that which is given to the tunica vaginalis testis, when a caustic has been ap- plied to it, for the cure of hydrocele; by which application, that membrane, suffers all that it can do, from irritation, yet the inflammation is inconsiderable until the tunic has ruptured.f If irritation from a wound or puncture were alone, suf- ficient to produce fatal inflammation; the violence done, by an incision made into the abdomen and uterus with the fragment of a butcher's knife, in the case related by Dr. Moseley and noticed in another part of this paper could not have been survived. It is not my design to deny that irritation is the conse- quence of wounds, for I believe there is no wound, how- ever slight, which does not produce some degree of irrita- tion, but, I think we have ample grounds for deciding, that local irritation from a wound is incompetent to the produc- tion of inflammation so extensive as that which follows a wound into a cavity. * Hunter on the Blood, Vol. II. pages 144. & seq. •J- Abernethy's Essay on Lumbar Abscess, page 56. 21 ■g - = AT a time, when cold was supposed to be actual mat- ter, and thought to be a stimulant; there could have been no difficulty in giving a plausible solution to the question, of the cause of the inflammation which attacks internal parts, when exposed to the open air; as the air is general- ly below the temperature of the body. Cold had stimula- ting powers attributed to it, from pain, redness and inflam- mation of the skin having been observed to follow expo- sure to it, and by the system having been observed to be strengthened by the application of it, in a certain degree. That the privation of an accustomed stimulus will pro- duce pain is well known, and the violence of the pain will be in proportion to the extent and continuance of the dimi- nution, within certain limits. This pain when caused by cold, arises from the actions of the exposed parts, being lessened and performed irregularly, but pain from expo- sure to cold, is not very violent, until a higher temperature is applied. The manner in which it is then produced, will be noticed in another place. That cold is not a stimulus is shewn by the weakness, torpor and death which are produced by its long continued application, by the effect which it has on the pulse and by its use in diseases of too great excitement. The increaf'e of ftrength, faid to be produced by cold, as in the cold bath, does not appear during the application of cold, and is entirely owing to the difpofition of living matter, to become more fenfible to its common stimuli, after they have been withheld for a fhort time. Which difpofition does not fhew itfelf in thofe cafes only, in which heat has been applied, after its abftraction for fome time; but its effects are almoft as finking in cafes where perfons have fafted for a long time. Some of the company of captain Bligh felt the fymptoms of intoxication from eating oyfters, and fome berries of an innocent nature, after they Jrad for feveral days eaten a very fmall portion of food. Dr. 22 Percival mentions a young phyfician of Geneva, who, when a fludent at Montpelier, fafled three days, after which, the firft nourishment he took was veal broth, and that had an intoxicating effect on him. » ■ AS all the above mentioned theories, appear in fome part, either defective or inapplicable. I fhall make an attempt to account for the inflammation which occurs on wounded cavities and their contents, in a manner, which has received the fandtion of no furgical writer. But I hazard it, at prefent, with extreme diffidence, both on account of the hafty manner in which I am compelled to advance it, and the flight fupport, which, a very limited time allows me to derive from experiments, or from medical and furgical writers. Before I proceed to fuggefl my ideas of the caufe of inflammation fupervening on wounded cavities, it mull be obferved that inflammation may be produced, ift. By preternatural flimuli acting on a part poffeffing only its due proportion of excitability, in which confifts its health; instances of this are afforded by cantharides, fome chemical preparations, heat of 212 degrees, &c. applied to the found fkin. 2ndly. It may be produced by ordinary flimuli act- ing on a part, the excitability of which has been accumu- lated by a temporary fufpenfion of their action, which rc.ay be noticed in parts of the body which have been expofed to a great degree of cold ; it is alfo obfervable in catarrhs and fome fpecies of cynanche. The effect of cold in rendering animal bodies more fenfible to heat, or incapable of bearing fo high a degree of it, mufl foci: have been learned from experience, by the inhabitants of cold countries ; and although they probably pofTefled uo correct theory, as to its mode of action, they did not neglect to avail themfelves of their knowledge in practice, as is fhewn by the mode which 23 they adopt, to recover perfons who have suffered from expofure to violent cold. That cold has the effect of making parts more fenfible to heat fubfequently applied, has been noticed and illuftra- ted by Mr. Hunter, whofe phrafeology, when treating on this point, is new. He fuppofes the quantity of life to be leffened by cold, and fays, flimulus mud be proportioned to the quantity of life. He fays farther, " Cold, according to its degrees, produces two very different effects, one is the exciting of action without leffening the powers, the other is absolutely debilitating, while at the fame time it excites action, if Carried too far ; in the firft, it becomes like fuitable exercife to the vafcular fyflem, as bodily exercife is to the mufcles, increafing flrength; but when carried or continued beyond this point, it leffens the powers and becomes a weakener, calling up the action of refiflance after the powers are leffened."....Again, " Cold produces the action of contraction in the vefTels, which is an action of weaknefs. A degree of cold fuddenly applied, which hardly produces more than the fenfe of cold, excites action after the immediate effect is over, which is the action of dilatation, and which is the effect of the cold bath when it agrees; and as cold produces weaknefs in proportion to its degree, its application fhould not be carried too far, for then it produces a much worfe difeafe, irritability, or over action to the flrength of the parts, and then indolence too often commences."* Between the doctrine advanced in this extract from Mr. Hunter, and the opinion of Dr. Brown on the fame fubject, I perceive no particular difference, except in terms. They both allow that the effect of cold applied for a fhort time is the exciting of action, after it is withdrawn, or a higher temperature is given to it, which takes place on leaving the cold bath. When a part has been expofed for * Hunter on the blood, vol. ii. p. 74. 24 a long time to a greater degree of cold, the difpofition to ac- tion is increafed fo greatly as to have inflammation or gangrene brought on by ordinary flimuli fubfequently applied, exam- ples of which are frequently feen in frofled limbs. It was, I believe, firft taught by Dr. Brown, that all sedative powers, weaken the tone of the fibre, which by accumulating irritability predifpofe to inordinate action on the application of a slight ftimulus. Cold, I think, is emi- nently intitled to be confidered a fedative power. That it produces debility is fhewn by the effect which it has on the pulfe and on the fkin, alfo by the general reduction of flrength which is obfervable in thofe who are expofed to it for any length of time. Of this debility, I prefume, an accumulation of excitability or by whatever name it may be called, an increafed aptitude to be acted on, to be the uniform confequence. An inftance of this debility from cold and confequent fenfibility to heat, is fhewn in the common cold days of winter on our hands and faces.— When we firft leave a room, the temperature of which is pleafant, and go into the cold air, the expofed parts im- mediately become pale and remain fo for a fhort time, after which, from an accumulation of excitability, leffen- ed tone, or weaknefs of the veffels of the parts, the ac- tion exifling in the fyftem will be fufficient to throw blood enough into thcfe parts to render them quite florid; and if we return to the same temperature, which had before been grateful to our feelings, or to one a little higher, the ac- tion will be so much increased, as to give considerable pain, and even to go on to inflammation and mortification. It has been conjectured that when any part of the body has been weakened by cold, the adjacent parts sympathize with it, and, as soon as the cold is removed, the action of the neighbouring parts spreads to it, giving to it a greater degree of action than its weakened state can bear, of which, inflammation is the consequence, frequently terminating in gangrene.* * Burns on Inflammation, Vol. I. p. 26". 25 It is not material to my present enquiry to ascertain, whether inflammation is induced by the sympathy just men- tioned, or is the consequence of cold being applied beyond the powers of resisance of the parts, or is produced by sti- muli acting on the accumulated excitability, which super- venes on debility. I incline, for various reasons, to the latter mode of explaining the phenomena, and one of the greatest weight, is, that it receives the support of all the arguments used by my preceptor Dr. Rush, in favour of his theory of fever; in either case, predisposing debility occurs, on this, an accumulation of excitability follows, on which any accidental additional stimuli, or even the ordinary stimuli will act with sufficient force to induce inflammation. I think it strongly in favour, of the truth of the expla- nation which I propose, of some cases of local inflamma- tion, that it accords so fully with the theory of fever of Dr. Rush, which has thrown light on various diseases, and led to innumerable improvements in medical practice. As the temperature of the internal parts of our bodies, is always considerably above that of the surrounding atmos- phere, whenever a direct communication is made between the cavities of the body and the external air; it is obvious, that by a known law of heat, a reduction of the temperature of the cavities must be the consequence. These cavities, being uniformly accustomed to a heat of ninety eight de- grees, a reduction of that temperature by a number of de- grees, which would have but little influence on the external surface, ever exposed to varying temperatures, may induce debility on the membranes lining the cavities; on which I suppose inflammation to follow on the principles which have been mentioned. I believe the redness, which is obfervable on the fkins of infants a few hours after birth, to be a flight degree of inflammation, and think the fudden change of tem- perature, to which they have been fubjected, is obvioufly the caufe of it. It is rendered more probable, that this is the true cause of the inflammation of cavities, when exposed to a tempe- D 26 rature much lower than is natural to them, when the extent in which the same principle may be observed to act, in the inferior orders of the animal creation and also in the vege- table kingdom, is taken into consideration. All that vast number of animals which go into the state of torpor, strongly evince the extensive prevalence of a prin- ciple which is beginning to be generally underftood and ad- mitted, which is, That animal matter becomes more sensible to its ordinary stimuli after they have been diminished or withheld for a short time. We learn on the authority of Fontana, that vipers which, during the winter had been kept at the temperature of 59 degrees, were destroyed in two minutes by exposing them suddenly to a temperature of 67 degrees; which is very far below that, which they easily bear and in which they are in full vigour during the summer. This fact is clearly in favour of the opinion, that cold has had the effect, on these animals, of rendering them infinitely more sensi- ble to the stimulus of heat, than they were before they had been exposed to cold. The Abbe Spalanzani obferved, that newts conceal themselves in the earth and become torpid in the month of October, when the thermometer generally flands at 54 degrees; after remaining feveral months in this flate, they re-appear in February, when the degree of heat is much lefs than at the time of their becoming torpid. No one, I believe, contends that there is any phyfical neeefnty, from the conftitution of thefe animals, that they fbould go into the flate of torpor ; indeed it is known to be otherwife, as the fame fpecies of animal will be fubject to become torpid in one climate and not in another.* They require a certain quantity of heat to keep them active, and this mufl be larger at the clofe of fummer, than they can bear at the commencement of fpring, furnifhing one of innu- merable inflances, in which it is obvious, that living matter becomes lefs fenfible to flimuli which are frequently repeat- * Professor Barton's Lecturrs. 27 ed. We here find the newts retiring on account of the defect of heat, when it is generally equal to 54 degrees; they continue in their flate of torpor, expofed to feeble flimuli, for feveral months; when, by fome change which has taken place in them during the time that they have fpent in their winter quarters, they are prepared to come forth in February, when the temperature is frequently below that of freezing. That it is defect of heat which caufes them to become torpid is fhewn by their remaining active, when kept in warm places ; and the change which takes place in the time of torpor, appears to confifl in their acquiring a capacity, of having perfect life fupported by a lefs quantity of heat. By which, I mean, the excitability of their fyftems has been accumulated and great action is produced in them by a flight flimulus. This principle, fo general and fo frequently manifefling its influence, could not elude the accuracy and penetration of Mr. Hunter, to whom it appeared in a variety of familiar inflances. He avails himfelf of it, to explain fome pheno- mena, which had not before been plaufibly accounted for- He notices the difpofition in eels to be fo violently affected by a moderate heat applied to them when torpid, as to be deflroyed by it in a few minutes. He reports the fame effect having been produced on fome other animals, as fnakes and lizards. On the fame principle, he explains the fpeedy death of birds caught during the winter, and brought fuddenly into a warm room. The immediate deftruction of animals palling from a low to a moderate temperature, may, I think, be fairly attributed to the violent action which arifes from the heat fuddenly applied to their very excitable fyftems, becaufe they become capable of bearing a degree of heat, when applied by the fteady and unerring hand of nature, equal and often fuperior to that which kills them, when afforded by art, without a due regard to their particular flates. The effect of cold in difpofing to increafed action on the fubfequent application of heat, is not confined to ani- 28 mals, but vegetables may be obferved to have a fimilar effe£l produced in them, of which a variety of facts pre- fent themfelves as interefting examples. It is particularly pleafing to notice the exiftence and influence of a law common to thefe two great orders of animated creation, forming another chain, by which nature feems to have connected her works. This agrees with the many cogent arguments which have lately been advanced to fupport the opinion, that a gradation has been obferved fo regular and infenfible, as to preclude the poffibility of drawing a line of Separation, and even to force us to admit, that there is no point at which animal life can be faid to ceafe, and vegetable life to commence. Which doctrine is rendered almoft certain, by the learned invefligation, and the able and beautiful vindication which it has received from profeffor Barton.f In the vegitable Statics of Dr. Hales, there are fome very interefting experiments, by which the effect of cold in predifpofing to action is clearly fhewn. In the fpring, when the temperature is ftill very little above the freezing point, the fap begins to rife in vines, and the force and rapidity of its motion are obferved to be confiderably in- creafed by a cold night having preceded a warm day. If the fun rifes clear, the fap continues to rife no longer than nine or ten o'clock, after which time, it was obferved gradually to fubfide until evening; which, I think, fhews unequivocally that it is not the heat alone independently of circumftances which caufes the fap to rife, as that is greatefl after twelve o'clock. It mufl, therefore, depend on the irritability or excitability, which is exhaufted by the heat acting on it from funrife until nine or ten o'clock; and the abfence of the fun every night fuffers the plant to accu- mulate a flock of excitability for the fucceeding day. The irritability of the hedysarum gyrans is faid to be exhaufted t Lectures on the affinities between animals and vegitables. 29 by the noon day fun.* And the experiments of Fontana fhew that the irritability of the sensitive plant is moft abun- dant in the morning, lefs at mid-day, and almoll imper- ceptible in the evening. It has alfo been remarked, that corn ripens in countries alternately cold and warm in a much fhorter time than in fuch as are uniformly warm. Thefe, are only inflances, in which the health and growth of vegetables are promoted by the alternation of heat and cold ; but there are not wanting others in which, to continue the analogy, mortification and death are the confequences of a tranfition, too rapid, from the tempe- rature of freezing even to that of a clear morning of fpring. All delicate vegetables and the young leaves and fruits of trees, are liable to be blighted after a frofty night. That this arifes from the flimulus of the heat of the next day, being difproportioned to the remaining quantity of life, or to the excitable flate of the vegetable, and is not the necef- fary confequence of the froft, is proven, by the mode which has been fuccefsfully pra£Hfed to prevent it; that is, by the fimple precaution of moderating the heat by the evaporation which will arife from watering the plants before the riling of the fun. Independently of the arguments which are afford- ed by analogy, drawn from the lower orders of animals and from vegetables; I am countenanced, in the opinion which I have advocated, by the facility with which it ap- plies to a number of cases, which have not been explained on any other principle. One of thefe cafes on which, I repose with great confidence, is that of the lungs, pleura and intercoftal muscles being lacerated, by a fracture of the ribs. In this cafe the air efcapes into the cavity of the tho- rax and into the cellular membrane; here no inflammation * I have here, as well as in several other places used the fafls whicb Jiave been collected in the third volume of Medical Extracts. 30 of confequence takes place, although air gets accefs to the cavity of a fhut fac and fhould, according to Dr. Monro, produce inflammation: This air, is frequently renewed, that firft taken in, finding its way into the cellular texture, it is alfo long continued in its application, and thefe accor- ding to the opinion of Mr. Abernethy are the two requifite circumftances, for the production of inflammation. I have in another part of this effay endeavoured to fhew that imperfection of the cavity, fuppofed by Mr. Hunter to be the caufe of inflammation, could not be denied to exift in this cafe; and certainly where a laceration of the foft parts has taken place to fo great extent, there muft be as much irritation as could be defired by Mr. John Bell. Why inflammation does not occur here, is not fatisfac- torily explained by either cf the writers, who have been mentioned. The reafon is immediately obvious, when the theory which I have embraced is attended to, the air in pas- fing through the lungs, the central point of animal heat, muft acquire a temperature equal to that of the body ; and is thereby rendered unfit, to induce the debility on the cavi- ties, which is neceffary to predifpofe thefe parts, to take on inordinate action, on the application of fo feeble a flimulus as that of their natural heat.* But if, along with this fracture and laceration, a wound is made through the integuments of the thorax, then the furrounding air gets accefs to the cavity, without having had its temperature increafed, and inflammation arifes in the manner which I have already ftated. Nor is this effect of temperature by any means confined to a few cafes of unfrequent occurrence; but it may be feen * It might be contended here, that the air in passing through the lungs is deprived of its oxygen, and thereby rendered incapable of stimulating the cavity of the thorax. A considerable portion of the oxygen which is taken in, in healthy respiration, is well known to be expired in the same state, and this, when the lungs are wounded, must pass unaltered into the cavitv of the chest; but we have no grounds on which to found the opinion that oxygen, after getting into the chest, would unite with any thing there, and stimulate that cavhy by the heat which would thus be produced: And I am acquainted with no fa<5t, which favours the idea of oxygen possessing more irritating powers than any other gas. 31 almoft daily in [the practice of phyficians; all catarrhal af- fections are produced in this way; and the range of this principle, includes all grades of action, from the tranfitory glow, which we feel in our noftrils, in paffing from the cold air, to a warm room; up to the fatal inflammation and gangrene, which take place on the application of heat after long expofure to intenfe cold. There can be no doubt, as to the fenfibility to the ftimulus of heat, being increafed by a previous expofure to cold. The pain which is felt on holding the hand near a fire, after having been in the open air on a cold day of winter, or after handling ice, is familiar to every body. Which circumftance, demands theadmiffion of this principle for its explanation; as the fame degree of heat would have produced no unpleafant fenfation in the hand, if it had not before been in a reduced temperature. I think it probable, that I have the authority of Mr. Cline to fupport me in the doctrine which has been contended for in this eflay ; but of this I am not certain. I recollect, that he attributes the inflammation of wounded cavities to a difference of temperature ; but whether he believes the doctrine of cold being a ftimulus, or in what he explains its action, I have not learned. I am encouraged to adhere to the theory which has been propofed to account for inflammation arifing in wounded cavities, by a confideration of the great advantage in prac- tice which may be obtained from its being afcertained to be true. If the lownefs of temperature fhould be proven to be the principal caufe of inflammation on internal parts of the body when expofed to it, a number of operations will be performed without hefitation and with fafety, which are now declined by furgeons, or undertaken with the mod painful dread of the dangerous inflammation which they know muft fupervene. The manner in which I fhould 32 guard againft inflammation, confiftently with my ideas of its caufe, is plain, and immediately prefents itfelf to view; and I flatter myfelf that the propofition of Dr. Beddoes, to have rooms filled with air, modified in fuch a way as to fuit the difeafes of his different patients, will be consi- dered a fort of precedent, and will ihield me from ridicule, for fuggefting the advantage that would probably refult from performing fome operations in rooms, of a tempera- ture equal to that of the human body. The operations which would thus become lefs dangerous, are all thofe in which ic is neceffary to make an opening into any of the large cavities of the body, for the difcharge of fubftances contained in them, as in operations for empyema, and thofe for the difcharge of extravafated blood, and any viscid or folid matter from the abdomen; alfo, all the cafes in which the cavities of joints are opened for the removal of fluids or cartilaginous bodies; and the operations for hernia when it is neceffary to lay open the fac. A mode of preventing inflammation on the expofed bowels in operations for hernia, which is pointed out by Profeffor Wiftar, gives a tacit acknowledgment of the truth of the doctrine which has been advanced in this enquiry. He recommends bladders of warm water to be put on the inteflines, which are unavoidably expofed in the operation: He has found this practice ufeful; its ufe could not be that of preventing air from touching the bowels, becaufe no care could obviate it, befides it has been fhewn, that air is not injurious to parts naturally defended from it. In these cases, I suppose, the heat of the water prevents the peritoneum from falling into that state of debility which would be followed by inflammation on the principles which have been advanced. To these, may perhaps be added, the operations for the discharge of large collections of pus. The success of Mr. Abernethy's mode of discharging the matter of lumbar abscesses, may, I believe, be attribu- ted to the fmallnefs of the punctures and their immediate 33 clofure, which prevent the temperature of theif cavities from being reduced, and thereby obviate inflammation; the fimple operation of paracentefis is fuccefsful for the fame reafon. The caufe of hectic fever confequent on opening lumbar abfceffes and other collections of purulent matter, being entirely unknown ; I may be allowed to venture a conjec- ture, that hectic fever is in no other refpect different from the ordinary conftitutional derangements arifing from local mflammation except that which depends on the health of its fubjects being injured by previous fuppuration. It is, I believe, on the fame principle that the caufes which produce inflammatory fevers in well-fed and healthy men, give rife to typhus fevers in failors, foldiers, and poor perfons who are debilitated by having been badly fed and crowded together in confined fituations, as on board {hips, in jails, and in the miferable habitations of the indigent. In one cafe, debility is brought on by a tedious and diftref- fing fuppuration; in the other, by an habitual deftitution of the necefTary fupply of food, &c. debility is alfo induced; which debility is of a chronic nature ; and this, according to ProfefTor Rufh, expends the excitability of the fyftem, leaving it in a ltate, in which flimuli generally act with too little force upon it to excite in it the commotions of (inflammatory) fever.f Two other operations, which are so formidable as to intimidate the moft intrepid operators, deferve the greateft attention from furgeons, and any propofition which affords the flendereft hope of their terrors being diminifhed, claims a candid confideration from thofe, whofe flanding in the |i* profeffion entitles them to difcountenance, or to admit and encourage any innovation, propofed as an improvement. One of the operations to which I allude, is the ex- tirpation of fchirrous and dropfical ovaries. I do not know that this operation has ever been performed, and as I had f Medical Enquries and Observations, vol. IV. p. 127. £ 34 no authority to fupport me, I had fcarcely dared to whifper my opinion of its feafibility, until I found it had been propofed a long time fince by the venerable Dr. Shippen, profeflbr of anatomy in this Univerfity. There is certainly nothing in the anatomy of the parts, which fhould deter furgeons from removing them, when from difeafe they have become incapable of performing their office, and en- danger life, or at leaft render it uncomfortable. We do not hefitate to take out cancerous eyes and fchirrous teftes when fuch facrifices are necefiary to preferve the lives of our patients. And, however ftrongly prejudice might oppofe this practice in its commencement, I believe it would be submitted to, when the nature of the cafe, and the flight permanent inconvenience which would be the confe- quence of the lofs of one ovarium, was fully compre- hended. All furgeons fometimes witnefs the pain, anxiety, and defpondency which are concomitants of thefe affections. The unhappy fubjects of them defpairing of a recovery, calculate on fpending their lives in a flate of wretchednefs and difeafe. • Under thefe circumftances, no alternative however painful, which gives a profpect of health, would be rejected. The urgency of the cafes, and the rapid manner in which they haften to a fatal termination; have compelled furgeons, to turn their attention to the diftreffes of partu- rient women; who from malconformation, cannot be de- livered in the natural way. For their relief, an operation has been occafionally performed, called the Caefarian fection which is perhaps the mod dangerous one in furgery. A larger proportion of the perfons who have been the fubjects of it,have died, than of thofe who have borne any other accre- dited operation. The danger of this practice being con- fidered, it is doubtlefs much to be defired that it could be difpenfed with, this, however, feems impoffible, and all that can be done, is to deprive it, of every portion of dan- ger, which is not infeparable from it, and intimately con- neded with the parts which are the fubjeas of operation . 35 I know not, in what manner, the irritability of the uterus is to be eftimated; and am therefore, unable to de- cide, what degree of inflammation would arife from an in- cifion made into it; I prefume, that a wound made in this part would be equally liable to become inflamed from irri- tation, as one, made in any other mufcular part of the bo- dy. But as the influence of temperature, is fo obvious, in caufing increafed adion and inducing inflammation, mor- tification and death in living matter, it is at least probable, that the fatality which has almoft uniformly followed this operation, may in fome degree, depend on the expofure of the cavity of the abdomen, and its contents, during the operation. This operation therefore, which has here- tofore been almoft always only a prelude to death, has an indifputable claim to be performed in rooms of the tempera- ture of 98 degrees. The danger cannot be augmented by it, but may poffibly be diminifhed. Among the very few inftances of this operation being fuccefsfully performed, there is one reported by Dr.Mofeley as occurring in the West Indies; a young negro woman, who was in labour, becoming impatient of the pain which (he fuffered, conceived the idea of of relieving herfelf in a fummary way, and with a common knife made an incifion into the abdomen and uterus, through which the child was delivered. The inteftines which had protruded through the wound, were replaced along with the placental portion of the funis, by fome perfon at hand, and a flitch or two were put into the wound. The medical attendant, who foon after arrived, fufpecting that fome dirt or other mat- ter had been thruft into the abdomen along with the intes- tines, took them out, examined and returned them, and at the fame time extracted the placenta through the wound. This patient recovered, although almoft every circumftance confpired to make the cafe peculiarly violent; the incifion was made with a rough inftrument, and the bowels hand- led and expofed much more than would have been neceffa- ry in a regular operation. As this cafe terminated favour- 36 ably, under fo untoward circumftances, it is fair to con- clude that it ought to be attributed to fomething else than chance, and I can conceive no circumftance to which it may with fo great probability be afcribed, as to the heat of the weather in that climate, increafed probably by a ftill more heated cabin. Mr. John Bell mentions a curious cafe of a foldier being wounded in the fide by a halbert, afterwards walking a mile with his inteflines hanging out, wrapt in the fkirts of his (hirt, and depofited in his hat: The roads were dufty, and the inteflines dry as parchment and blackened with dull, when he obtained the afiiftance of a charitable old lady, who bathed his inteflines with warm milk, and replaced them. It muft be obferved, that " the weather, it being mid-fummer, was intenfely hot." Here it appears that neither the dufl nor other irritation was capable of exciting a fatal inflammation, which, I think, would cer- tainly have been the confequence of expofure, fo long continued, to a low temperature. When I refolved to write on this fubject, I flattered myfelf with the idea, that I fhould be able to prove the truth of my opinions, but was obliged to relinquifh a feries of experiments which I had conceived for that purpofe, by the unfavourablenefs of the feafon of the year, in which only, I had an opportunity of attending to the fubject, and for the want of feveral conveniencies which are indifpen- fable to accuracy and fuccefs in experimenting. It is, however, pleafing to me, to reflect that the truth or fallacy of my explanation, is capable of being afcertaindfi with abfolute certainty ; and I hope it will be deemed worthy of examination, by some abler hand and more experienced. experimentalift. THE END. Me. » '. , ;ijn..—i., ..:;•:■ . ■ iblliiljH;:;.r:-:j,.:-:i::;-"'.M: ':: '■ ■ ■■;■,::•!■;!-■:■■:; ;. I, I- 0114