ON THE PRINCIPLES AND PRACTICE OF PHYSIC,

231 the former, and there is less local disturbance in the latter. By the term chronic inflammation, I mean an inflammation which begins and goes on very slowly, and which is generally unattended by -fever for a considerable time after its formation. When inflammation is acute or subacute, the system is attacked, as it were, by storm ; -an alarm is excited LECTURES throughout the whole, or, to speak less figuratively, a considerable disON THE turbance, called fever, is produced ; PRINCIPLES AND PRACTICE but when inflammation is chronic, it OF PHYSIC, begins and proceeds so very insidiously, that litt!e or no general BY DR. ARMSTRONG. disturbance arises for some time. I shall have occasion also to use the terms active inflammation. and passive inflammation. When inflammation is Theatre of Anatomy, Webb Street. active, it is attended by a very high degree of fever, by a remarkably hot skin, and by either a full expanded LECTURE 6. or a smaller, but a hard conDR. ARMSTRONG briefly recapitu- pulse, tracted pulse, feeling like wire or lated the phenomena of inflammation, beneath the finger. But and the pathological conditions on whip-cord whatI mean by passive inflammation, which these phenomena depend, and is that attended a subdued or then proceeded to the piincipal di- masked form of by in which the fever, visions, and to the immediate and heat upon the surface is scarcely remote effects of inflammation. higher than natural, and in which the GENTLEMEN, pulse is remarkably soft and compresInflammation is acute, szeb-acute, sible, the heart’s action being really and chronic, As in these Lectures I diminished in natural force, while the shall often use these terms, it is right capillary vessels of some part remain that I should attach a definite mean- engorged. We have an example of ing to each ; and, indeed, it is my in- the active and passive inflammation in tention to explain, as I proceed, every some cases of typhus fever, the active such term as I may have occasion to at the commencement, and the passive adopt. If ever 1 forget to do so, I at the end. At the former period, hope that you will demand an expla- the skin is in such cases intensely hot, nation , for if I have a definite idea, and the pulse expanded, while some I can find a word to express it; but organ is acutely inflamed; this state if I have not a definite idea, I wi)l not continues for five or six days; then attempt to conceal it, but at once ac- the heat begins to fall on the surface, knowledge to you my ignorance on the pulse becomes subdued, the musthe subject in question. By acute in- cular power prostrate, and the tongue flammation, I mean the highest degree glaze(1 and brown. Now in what does of inflammation, which arises sud- this change consist ? There is always denly, advances svithrapidity, and ter- a remarkable deficiency of force in minates in a few days, if left to itself. the action of the heart, whatever may By sub-acute inflammation, I mean a be its frequency. In active inflamlower degree of inflammation than mation, the heart’s action is increased,; the acute, which arises less suddenly but in the passive it is diminished. distinction between active and and severely, has a more protracted course, and, if left to itself, does not passive inflammation is of the greatest terminate,in the first week, but runs importance in the practice of physic. If you were to treat an active -inflamon to the second or third week. When inflammation is acute or snb-acnte, mation in the same manner as a pasit is , attended by fever, which is sive one, yon would be extremely un-

higher in

the same intention,and various metallic preparations. Narcotics were found to be the best applications, and they are also the only medicines which allay the sufferings of the patient. In my next Lecture I shall conclude the subject of tumours.

I

This

232

successful.

If,

on

yon were to treat a

the other

" hand, saying, Sir,

what you affirm is conlaw."’ 11 Contrary to law !" exclaimed the other : " Young man, yon should never say that a thing is contrary to law, because you may be called upon to point out that law particularly; but you must say, that it is

passive inflamma- trary

to

tion as you would an active one, it would generally be attended by fatal effects. If, for example, you were to treat an inflammation of the lining membrane of the bronchia in the last stage, as you would an inflammation contrary to tlae fundamental principles of the pleura in the first stage, the of the British constitution, and then destruction of the patient would in all yon are perfectly safe, for nobody can probability be the consequence of ever understand exactly what you mean. (A good laugh.) If, therefore, such rashness. IfI have explained myself with any any of you ever wish to put an end to degree of precision, you must have an argument in which you may be understood how inflammation imme- getting into a scrape, you have only to diately arises from common causes; say, that the affection is dependent it does so in two ways : 1. By the in. npon constitutional disorder, or con. creased action of the heart operating stitntional derangement, words which on a weak organ, just whether that mean any thing or nothing, and which increased action arise from depres- are admirably suited to the purposes sion, stimulation, or irritation, when of sopliistry. Biat, to be seiious, if the the latter only amounts to local simple word constitution, in physic, mean any excitement. Hence five or six thing distinct, it means the whole rent persons, exposed to the influence body, and as the whole body is made of the same agent, will have inflam- up of pai ticular parts, so we must mation produced in five or six diffe- look to those parts, solid or liquid, rent organs, because these happened for an explanation of all morbid afto be the weak parts, and, therefore,fections. Logically speaking, there predisposed to the inflammation. 2. Itis no such thing as constitutional disarises from an irritant, which pro order separate from local disorder or duces not a local simple excitement,, disease. We have, I say, no sub. but an actual inflammation, which may stantial reasons for supposing that arise directly from an impression, any affection is constitutional, indemade upon the nerves by a foreign pendent of a local disturbance somebody, or it may arise indirectly, where ; it is seated either in some through some change in the momen- part of the solids or liquids of the lititum, qnantity, or kind of blood acting man body ; and if we take the trouble to examine, we shall, as I before said, on the nerves and capillary vessels. Having premised these remarks, I find it in some of these influencing the proceed to investigate the termina- rest. This general use of a nontions, or, rather, stages of inflamma- descript term, of a mere quibbling tion ; but, for the sake of simplicity, deceit, has been the cause of many I shall call them the deaths, by the indistinct pathology and dangerous practice to which ithas Effects of Inflammation. led. If I find such momentous evils These effects have been called local arising from thf abuse of language. and constitutional. The term local is I shall fearlessly expose tiiem. But very distinct, since it applies to a par- I speak not against persons here, ticular part of the body, and nothing only against opinions and practices; More ; but the term constitutional is and, meeting with terms fitted to remarkably obscure ; it is one of our support and perpetuate errors in both, cant or convenient words, more cal. I cannot pass them over without a culated to conceal ignorance than to decided censure. explain facts; it is a mere subterfuge; The effects of inflammation are imone of those many juggling expres- mediate and remote. The immediate sions by which we deceive ourselves, effects are those which occur in or and mislead others. A late notorious about the inflamed part. The remote politician once held an argument with effects are those which are produced a young man, who, in the course of in the distant parts, solid and fluid. it, interrupted him rather abruptly by This view of the remote and imme.

diffe-

233

diate effects of inflammation involves things, the consideration of the external pathology and of the internal two

pathology. both, if

In the

we are ever

investigatioa

of

to have any pre-

notions, we must view them as organically connected, and entirely cise

exclude such vague terms as constitutional disorder and constitutional de-

rangement. in reference to past times, London has produced three great men in the medical profession, HARVEY as a physiologist, SYDENHAM as a physician, and HUNTER as a surgeon. The last named individual threw considerable light on the subject of inflammation. He philosophically endeavoured to mark its different changes, to one of which he aHixed the expressive term adhesive, to another suppurative, and so on ; but as this method has not been generally followed by physicians, I shall take the liberty, for the sake of distinctness, of introducing some slight changes in the nomenclature of the effects of inflammation. The immediate or local effects of in-

flammation

chlcuy the following : 1. Effusion: admits of three subdivisions; are

which the simple, the adhesive, and the szr,ppurative effusion. The simple effusion is either an increase of the natural secretion of the part, or the transudation of blood. We see an example of this when the eye is inflamed ; an in. creased effusion of tears takes place, and sometimes there is even an escape of blood between the conjunctiva and sclerotic. The same thing happens in the other parts of the body; in the mucous membrane of the air passages, and of the bowels in particular. But haemorrhage, as CELSUS just1y observes, may occur in three ways : 1. From a rupture of avessel; 2. From an erosion of a vessel ; 3. From transudation. In inflammation, the effusion of blood is generally by transudation ; the blood escaping as if from the mouths of the vessels, as CELSUS has expressed it, per ora venaruzn." The second kind of effusion is the adhesive effusion. This is an effusion of a material which has been termed coagulable lymph, and, in chemical language, fibrin. What is effused appears like jelly, and is sometimes

copiously ponred forth membranes internally.

from serons It serves for abond of union between divided parts. But sometimes it unites the surfaces of natural structures toge. ther, as the pleura pulrionalis and the pleura costalis. ,This union of parts takes place in two ways ; first, there is an effusion of lymph; in the next place, there is a streak of blood observed on that part of the effusion lying in contact with the natural surface : this streak of blood becomes a cylinder ; it ramifies ; the outer layer is formed of soft blood, the inner layer is composed of fibrin ; it becomes permeable, and, circulating blood, the parts are finally knit together as one structure. This fact, the knowledge of adhesion being the principal bond of union, is extremely useful when applied to surgery. CELSus distinctly speaks of it as a mode which nature adopts to prevent the after occurrence of haemorrhage, and has distinctly pointed out the method of tying di. vided arteries ; yet this fact was overlooked for many centuries, so that surgeons used the actual cautery, during and after operations, to prevent haemorrhage, till the ligature was ill.. troduced by AMBROSE PARE, a French surgeon. BENFDICTUS, TALIACOTIUS, the In. dian Brahmins, DUHAMEL and HUNTER, have all shown that a part of the body may be lopped off and united again, by adhesive effusion, to the part from which it had been divided. I recollect a case in which a man had?

by

some

accident, completely

cut

off

of his fingers ; it was brought to a surgeon, an acquaintance of mine, who cleaned the cut surfaces, and accurately replaced them ; the parts united, and thus the finger was saved. It shows how careful we ought to be in forming our opinionsy that we should not reason on any thing a priori, but entirely from facts. a part is divided, and the edges having been brought together, they at once uuite, the wound is said to be healed by the first intention, a term used by GALEK to distinguish thi& mode of union from that by granulation, which he called healing by thesecond intention. The third kind of effusion is the the top of

one

When

suppurative.

auppnration

is the

se-

234

cretion of

pns from the- vessels

of an It is a-fluid like cream; and if you view it through a microscope you will discover that it contains minute globules. The suppurative effusion is more common in some structures than others, especially so in the cellular membrane ; and, when it occurs in a deeply seated part, it frequently has a tendency to advance towards the surface of the body. Sometimes we see examples in which the simple adhesive and suppurative effusions are taking place at once, as in the common boil. In other cases, we may see the effusion of mucus,

inflamedpart.

organization of lymph.

It

frequently

happens that the substance which

is resembles the natural structure of the part which has been injured, but this is not always the case. The restoration of injured parts by granulation is sometimes very extraordinary indeed. The CARDINAL DE RETZ mentions, in his Memoirs, that he saw a man in Spain who had two legs, but that you will say was nothing marvellous ; yet in this particular case the two legs, or rather one of them, was most marvellous, for the Cardinal conversed with persons who affirmed

reproduced

that they knew the man previously lymph, and pus, successively taking when he had only one leg. How do place from the same membranes; as, you suppose that this large regenerafor instance, when an individual is tion had taken place? Why, simply seized by an inflammatory affection by anointing the stump with holy oil! of the air passages ; he first expecto- (A laugh.) Now-a-days, however, rates a thin mucous fluid, next some some parts of the :body are not to be shreds of coagulable lymph, and lastly regenerated even by holy oil, which pus. There is a study which might has lost its efficacy’ since the time of prove exceedingly useful, namely, the the Cardinal. Muscle is not repro. chemistry of. the living body; by it duced, neither is cartilage, as CELSUS has remarked. But a very learned we might be enabled to detect minute changes in the qualities of secreted empiric, travelling about the country, fluids, and connect them with the once met with a man who had a black structural conditions from which they spot on the end of his nose; he persuaded him to have it removed. -It apparently proceeded. The second immediate effect of in- was removed accordingly,’but a hole

flammation is

remained in its

Ulceration. Ulceration is a breach of the continuity of a part through absorption. All the arteries of the body may be said to be employed in furnishing supplies to different organs, and the superfluity is removed by the absorbWe have many familiar exents. amples of absorption in morbid affections. One may suffice for the purpose of illustration. A man receives a blow on the face, and that appearance is produced which is commonly called a black eye; the blood effused by the blow is gradually, and at last completely, taken away by the absorbents. You will most frequently find ulceration occurring in weak habits, and in those parts of the body which have a low dezree of organization. Some parts, especially arteries, resist nlceration remarkably. The third immediate effect of inflammation is Granulation. Granulation is a regeneration of a part of the -body by an effusion and

reproducing the destroyed cartilage, although he had before promised

stead;

his

superior art

not

that he could make flesh grow like

grass ! (Another laugh.) Granulation is merely the organization of the lymph which has been effused ; and by this alternate effusion and organization the part becomes regenerated in points somewhat like grains, and hence the distinctive expression. The above is what takes place in regard to the vascular system, but the probability is, that the nerves are also regenerated from the high sensibility which the part renewed acquires. The secretion diminishes,the skin contracts like a purse, and granulation ends by cicatrization or the formation of something like skin, if not skin itself. In the surgical treatment of wounds, we imitate or assist this process of nature by using bandages,

through which we cause granulating portions to contract, and at length heal. The

fourtla immediate effect ofjn-

flammation is

235 state

Mortification;

varely

occurs

there, the patient

which is separable into two stages ; the generally dying before the inflamma. stage of gangrene, and the stage of tion has reached that point. These sphacelus. Gangrene is a threatened are the principal immediate effects of

forming mortification; it is an inat the highest point in which the heat, circulation, and sensibility of the part remain; the skin is slightly purplish, and there are vesicles filled with a bloody fluid or with serum; yet, I repeat, the heat, sensibility, and circulation remain ; and these remaining, it is perfectly sepa. rable from sphacelus, which is the com. plete death of the inflamed part. Gangrene, however, is not necessarily followed by the death of the part ; the inflammation may become less, and

inflammation ;

or

,

flammation

’, might

terminate in effusion of adhesive rnat. ter, or by ulceration. It is by ulceration that a slough, a dead part, is

separated from the living body. Frequently thereis not much additional disturbance

produced at the time the is forming; but when the slough is about to separate, the demands made upon the powers of life appear to be so great, that a hard struggle ensues for life. A patient, for example, is worn out by a long fever ; he lies in bed on his back; the part on which the pressure is most made becomes discoloured, then black, and at last completely dead ; the separation of the dead part byulceration is accompanied sometimes by excessive disturbance ; but if he survive, the part is afterwards filled up by healthy granulation. Sphacelus, on the contrary, is the complete death of a part. It is livid ; the heat, circulation, and sensibility are extinct; the cuticle separates ; and there is the most offensive smell. The blood coagulates in the vessels of slough

or

but other local effects be adduced, such as thickening

contracting of

hardness If the

or

parts, and

some

softness of others.

oesophagus

or

urethra, the

rectum, be inflamed, thickening, and consequent contraction, of

pylorus

or

their calibre occur, commonly called When inflammation atstrictures. tacks the substance of the lungs, they often become hard, or what is technically called hepatized, from an effusion of adhesive matter into their cellular connecting membrane ; whereas, if inflammation attack the substance of the brain, it thereby often becomes remarkably softened, and, in likemanner, the mucous membrane of the intestinal canal is often rendered pulpy by the same cause. The next changes are vchat I.-denominate the .

Remote Effects of Inflammation. These are mainly to be sought for and will be found—1st. in the nervons system ; 2d. in .the sangniferous system ; and,3d. in the changes resulting from the combined disturbance of these two systems. It is a very curious fact, that when a very small part of the body sustains a certain accumulation of blood in the capillary vessels, that accumulation,

being continued, produces in the

not

only

a

of the part, but subsequently in the whole nervous system ; which influencing the heart’s action, the sanguiferous system becomes likewise disturbed. Thus, by an originally small and apparently a sphacelated part, and, on examining slight disorder, first the m liole nervous them after death, you find lymph system, and secondly, the sanguifeeffused on their sides ; sometimes in rous is brought into consent, and this the smaller vessels only, at other times fact we express by the term sympathy ; in the larger vessels. But even before the nervous system, like an electric complete sphacelus occurs, the blood cllain of communication, connecting undergoes a change in its constitution, one part of the body with another. the red particles having a flocculent Next, then, a change supervenes in the distribution of the blood, and the appearance. Some parts are more disposed to secretions of different organs are palresist mortification than others, as the pably affected ; the tongue is fnrred, internal organs, the heart, lungs, in- the stools unnatural, and the urine testines. It is -a very common thing turbid. The blood itself, in many cases, for persons to say that a man died of becomes altered, exhibiting, on abafter it has coagulated, the mortification of his bowels, butthat

change

straction,

nerves

236

buffy coat, an appearance connected should arise in the weak parts. It is with the degree of the animal heat, all very well if the internal organs

and therefore it is present in some merely sustain a simple excitement, inflammations and absent in others. but let any one become inflamed, and But how are these two systems con. especially the mucous membranes, and nected internally ? They are not only ten to one but he remains in ignorance connected with each other throughoutof the existence of such inflammation. the body, but more intimately so Pure surgery, therefore—surgery abin all the noble organs, if I my be stracted from physic—is a vampire, allowed to use such an expression. Itwhose daily food is human blood. is to the condition of these organs But in despite of the defective plans that we must look for the fatal effects of surgical education, there are many produced in the progress of external accomplished surgeons, particularly in this metropolis. I would strongly reinflammation. During the course of all external commend yon to read the first Lecture inflammations which disturb the heart’s of one, who resides in Edinburgh, action, we should look to the internal Dr. JoHN THOMPSON, on the conpathology, to the state of the internal nexion between Pliysic and Surgery; organs, which we shall find in one ofit contains more useful matter, in a two conditions ; we shall find them small compass, than any thing which either in the state of simple excite- I had before seen on the subject. ment, or the state of inflammation, GIBBON has observed, that there are terms which I have before explained. two modes of education, one which If the inflammation be external only, we receive from others, and another the blood circulates more rapidly which we communicate to ourselves. through the whole body; and if no in- There have been, and are, men who ternal organ be pre-disposed to inflam- have broken through the trammels of mation, the state of the internal organs scholastic and collegiate authority; is merely that of simple excitement. who have struck out a new path for This is a point of great practical im- themselves ; and I advise you also, in portance, in a surgical view, and one all cases, to exercise your own judgwhich ought to be well understood. ments, and step beyond that stiperBut if a patient die after an ope- ficial system of education which is ration, and survive the first shock, the sanctioned by some colleges of surcause of death will generally be found geons, where examinations are held to be an inflammation of the internal almost entirely without a reference to organs, which arises during the pro- physic, as if the external parts had gress of the subsequent fever. Sur- no connexion with the internal parts geons, therefore, should pay the most of the body. minute attention to the state of these But, again te pnrsue the original the remote effects of inflamand confine it to not subject, organs, merely the condition of the external parts. mation are, first, to be found in the Indeed those individuals who do not nervous system; secondly, in the sanknow how to investigate and treat guiferous ; and thirdly, in the cominternal affections rightly, can have bined effects arising from the disno claim to be considered scientific tnrbance of both systems. As an surgeons. If any man be ignorant of example of the last, I might adduce the principles and practice of physic, the prostration of muscular power. he is, for the most part, quite incom- The respiration is at last much inpetent to decide upon the propriety peded, partly, no doubt, through the of many operations ; first, because he eighth pair of nerves; but the respiradoes not know how far the preventive tion becomes weakened in part too efficacy of physic alone extends ; se- through the prostration of the whole condly, because he cannot estimate muscular system. The parietes of the either the condition of the interiml chest are not raised high enough; the organs, or the probable influence of diaphragm does not contract fully; an operation upon them; and thirdly, the lungs, in a word, do not receive a because when he does operate, he sufficiency of vital air; the heart’s action cannot properly conduct the after flags ; the blood is accumulated on its treatment, if any internal disorder right side, and not duly decarbonized, ,

237

ance, and

the veins returning the blood from the

notwithstanding

the cele-

brain, as well as other parts of the brated works of MORGAGNI, Larcrsr, body, become finally congested ; and thus, between the Inngs, brain, heart, SENAC, and CoRVISART,onthe diseases and blood, death takes place, rather of the heart, M. BERTi-4’s work confrom the remote than the immediate tained some discoveries in the pathoeffects of inflammation.

Having said thus much upon inflam- logy of these affections that had enpossibly you might expect me tirely escaped the observation of those to give a general Lecture on its treat2ne2it; but such a method of proceed- who preceded him. The copy before ing I hold to be absurd and hazard- us is an edition just published, and is ous, because in practice we have not edited by the friend and pupil of the to deal with general disorders, but with particular facts, -which, varying, author, M. BOUILLAUD. The points in require a correspondent change of which BERTIN’S book differed from treatment. It is commonly said, that bleeding, those of his predecessors on the same blistering, purging, and a spare diet, subject, related principally to the disare to be employed for the removal eases affecting the muscular substance of inflammation; but the treatment fitted to one case of inflammation is of the heart. CORVISART, who had mation,

,

different from that fitted to another. There are, in truth, various circum-

written

on

the diseases of the

heart,

short time only before the appearstances which modifv the treatment; the structures attacked; the degree of ance of M. BERTIN’S work, adopted a inflammation ; its duration also; the the particuremote causes, common and peculiar ; classification, respecting the age, sex, and habits of the parties, lar affection to which we have alluded, all demand a deliberate consideration. founded on the generally received, For these, and other reasons which erroneous opinion, that a dilatathough I in be next added, shall, might my Lecture, commence the illustration of tion of the cavities of the heart always particular inflammations, with the ap- co-existed with an augmentation of its propriate treatment of each. size. In 1811, our author read a paper a

before the IN3TITUTE of France, m which he demonstrated, by numerous Traite des MALADIES du CŒUR et des facts, that dilatation does not always GROS VAISSEUX, par R. J. BERTIN, accompany thickening of the parietes Professeur a la Faculté de Paris, -c. of the heart, that this thickening may Redige par J. BOUILLAUD, Docteur en take place, and the cavity preserve its natural size ; and that even hypertroMédecine de la Faculté de Paris, &c. avec sixplane7tes. Paris, 1824. phia may co-exist with a diminution of one or more of the cavities. HYPERTreatise on DISEASES of the HEART and TlWPHIA is the modern term, which the LARGE VESSELS, by R. J. BERTIN, corresponds to that of ANEURISM of

REVIEW.

Professor to the Faeulte of Paris, &c. Edited by J. BOUILLAUD, Doctor in Medicine, &c. with six plates. Paris, 1824. As long ago as the year 1811, the vo-

lume before us first made its appear-

made use of by CORVISART. We will state in CORVISART’S own words the sense in which lie uses this term, and then our readers will be

the heart,

able better to understand its

plication.

misap-