Dissertations on Inflammation, Vol. 2

by John Burns

When these sinuses communicate with joints, and depend upon diseased cartilages, tendons, or articulating surfaces of the bones, we can do very little in the way of curing them by injections or incisions; because we cannot thus remove the disease of the joint, but may increase it. Issues placed over the joint, with rest, cleanliness, and good diet, country air, &c. are the remedies chiefly to be employed in these cases; or, if hectic be induced, and these remedies fail, we must remove the diseased part, if this, on account of its situation, be practicable. When, however, these sinuses are superficial, and depend upon tendons not immediately connected with the articulation, it may be useful to lay them open, and treat the disease of the tendons with caustic, like a caries of a bone, or with escharotics, and stimulating applications.

The fourth species of sinuses, are those where a specific action exists[39], and prevents the healthy ulcerative action from forming. Of this kind is the scrophulous sinus, which is generally accompanied with a caries bone, or diseased cartilage, and, therefore, is a complicated sinus[40]. This is distinguished, where the bone is diseased, by a shining or polished red skin, like a cicatrix, surrounding the fungus papilla at the orifice of the sinus, or the scrophulous-looking sore which exists there. When no caries bone exists, we have no papilla, but only the diseased ulcer at the orifice. In both cases, there are generally the marks of a scrophulous habit. In the first case, we are to treat the sinus as if it were of the third species. In the second case, we are to treat it as if of the second, conjoining the proper remedies internally, as will be mentioned in considering the cure of scrophulous action. These sinuses, although healed, have a tendency to break out again, especially in the spring or summer.

The effects of the suppurative action upon the constitution, may be divided into those which are dependent upon the formation of the action, such as coldness, listlessness, &c. which are common to all new actions; and those which are peculiar to the action when fully formed. The first set requires no particular treatment, with an immediate reference to their removal; but their presence indicates the necessity of changing our method of cure, if we have not already done so. In conjunction with proper local applications, we must give light nourishing diet, with or without wine, according to the extent of the action and the weakness of the patient. Rest, and general warmth, are also necessary; but the heat ought not to be carried so far as to produce any considerable sensation, or sweating. Diaphoretics have been recommended[41]; but there does not appear to be any necessity for their exhibition; because the cold, and other symptoms which we intend to relieve, depend upon the state of the local action, and are only to be removed by fully forming this action. Heat will not cure this coldness, or shivering, when the action which causes it is extensive; but, on the contrary, will frequently increase it, by accelerating the formative process. The immediate effects, then, or the primary symptoms of suppuration, require no particular treatment, with a view to their own removal, but are to be attended to as marks which point out the necessity of a change of treatment, with a view to keep up the action which induces them, and to prevent it from producing bad consequences afterwards to the constitution. Sometimes, indeed, in delicate people, suppuration at this period produces hysterical symptoms, such as languor, flatulence, or sometimes starting, tremors, and hysteric paroxysms, more or less distinct. The slighter affections of this kind may be frequently removed by a little warm wine and water; the more severe, by anodynes, conjoined with aromatic waters.

The second set of symptoms, or effects, are those which have been already described under the name of hectic, the production of which has formerly been explained. This action, when slight, has been called weakness, and has been considered as dependent upon the quantity of the discharge; but, for the reasons formerly mentioned, this cannot be admitted. The cure of this state is to be attempted, by lessening the local action, at the same time that we give soups, and other articles of nourishing diet, with a moderate proportion of wine, if this do not quicken the pulse, and produce heat of the skin. Anodynes in the evening, by procuring rest, will also be useful; but none of these remedies will produce their proper effect, unless the patient respire a pure air. Bark is considered as useful in these cases; but, unless good diet be conjoined, it is not of much benefit. If, however, we give the means of increasing the quantity of vital power, bark, by inducing an action more nearly resembling the natural one, will be serviceable; but, for this purpose, it must be exhibited in full doses. It is from giving this medicine too sparingly, and in cases where other causes, tending to counteract its effects, such as poor diet, bad air, &c. are allowed to remain and operate, that bark has been brought into disrepute.

When the general action is very considerable, then the exquisite hectic is induced, and the situation of the patient becomes alarming. When the local action is simply the suppurative or ulcerative action, we may consider that the general disease is also simple, and are to attempt the cure by the remedies which have been just now mentioned. In conjunction with such local applications as tend to check the local action, we must have recourse to all those means which tend to strengthen or renew the natural action of the system in general; for which purpose, we must attend, in the first place, to all the particular functions, or individual parts; and, in the second, to the whole in the aggregate. Under the second head are included bark and wine, with moderate exercise[42], and proper diet; in the choice of which, we must be directed by the nourishment which is yielded, and by the capability of digesting the articles which we employ. In general, milk, soups, and jellies, answer best. Under the first head are included such remedies as tend to promote digestion, such as steel, bitters, mineral acids, &c. although in general the bark will supersede their use. The state of the bowels must also be attended to, avoiding costiveness on the one hand, and diarrhœa on the other. The secretion of the skin must also be regulated, stopping the colliquative sweating, if possible, by getting up for some time when it commences[43]. Lessening the quantity of bed-clothes, for a few minutes, will also sometimes interrupt it; but when it has continued long, it can only be checked by removing the diseased action[44]. A full dose of the bark given before the accession of the sweat, may sometimes, by influencing the morbid action, prevent the discharge. The respiration must in particular be attended to; for, by breathing country and pure air, the action of respiration is more fully performed, and, consequently, the source of vitality is increased, and the effects of our other remedies are increased. The importance of a change of air can only be known by those who have observed how fast patients have recovered from operations when removed to the country, and clean lodgings, with well-aired beds, although before this they were daily sinking. Indeed no capital operation, which is likely to induce the suppurative action, ought to be performed, where cleanliness, and a free circulation of air, free from fœtor, cannot be procured.

It is not yet discovered that any remedy has a specific power of removing the hectic, or diseased formative action, more than the local purulent one[45]; and, therefore, we are obliged solely to trust to these already mentioned, which have a natural tendency to increase the healthy action, or induce one nearly similar to it, and especially to a proper local treatment, by which we remove the exciting cause.

When these remedies fail, and the disease seems to continue, or increase, in spite both of general and local remedies, then we must, if it be practicable, remove the diseased part by an operation; and, in doing so, we must remember, that delay beyond a certain period is dangerous; because the general action becomes so rooted, and the strength so reduced, that recovery cannot take place. Operating in these circumstances, therefore, can only hasten death. The wound will not unite nor heal, and the general action will continue unabated.

When the local action is specific, the general one is also different from the simple hectic; and, therefore the remedies which are useful in simple hectic will not be of equal advantage in these cases, unless a specific remedy be conjoined, as, for instance, mercury prudently exhibited in the venereal hectic, dependent upon a neglected local complaint. The most frequent instance of specific hectic is the scrophulous; for the cure of which we possess no remedy which acts with certainty. Whenever, therefore, the local complaint cannot be cured, and the hectic increases, we must, if possible, remove the diseased part[46]; after which, the general action, notwithstanding its specific nature, most commonly declines; but the constitution still remains, as formerly, scrophulous, or even more so than before. That this is the case, would appear from the following fact: If a person slightly scrophulous, although originally sprung from a scrophulous stock, or in whom the constitutional disease seems to be disappearing, in consequence of intermarriages, &c. has, by means of a local injury done to a joint, &c. the scrophulous action excited, and consequent hectic, that person will, after cure, have the tendency to scrophula stronger in him than formerly; and the disease will even frequently be communicated to his children with its original violence.