Part 2

It is a common opinion, that the blood ought to be taken, if possible, from a vein which arises from, or near the affected part; that, for instance, in phrenites, we should bleed in the jugular vein; in inflammation of the feet, we should bleed in the leg, &c.: And, when this can conveniently be done, it may be preferred; because, it not only possesses all the advantages of general bleeding from any other vein, but also may be supposed to produce, in a slight degree, a topical evacuation. If, however, the veins be so small, that we cannot detract enough of blood, and sufficiently quickly; or if, from any other cause, we cannot do so, then, if the general action be violent, we must have recourse to another vein, as the loss to be sustained, by confining ourselves to this vein, is infinitely greater, than any good which can be derived from it, as a local evacuation. Indeed, when we consider the laws of the circulation, we must allow, that very little good can be done in this way, as a local detraction; because one vein does not lose more blood than another, except during the moment of the flow.

The blood, when drawn during inflammation, has always a buffy coat, which is, in general, thicker, and more concave, in proportion to the violence of the inflammatory action; and the continuance of this condition, is one circumstance which points out the necessity of continuing our evacuation: But the mere existence of a buffy crust, is not, without these circumstances, any infallible sign of the necessity of bleeding; because this crust is to be found on the blood, after the inflammation has begun to become passive; and it is to be found also, when mortification is approaching; we observe it likewise very frequently upon the last cup of blood which we find it necessary to take away. In these cases, however, the crust is much softer, generally thinner, always flat, instead of concave, and looser in the texture; it is also more of a greenish hue. These circumstances, conjoined with the state of the pulse, will enable us to judge, whether we should totally desist from, or continue our evacuations with caution. Most frequently they forbid farther bleeding.

Cold, or the subduction of heat, is chiefly useful as a topical application; but it is also proper to be applied, in moderation, for the abatement of the general fever, unless we be desirous of procuring perspiration. The quantity of bed-clothes ought to be lessened, cold drink should be allowed, and a free circulation of cool air into the room. The application of cold, however, ought, in general, only to be carried to such an extent as shall be sufficient for diminishing the morbid degree of heat, and not so far as to produce sensible cold, or the sensation of cold; because this, in many instances, will be pernicious, upon the principle of the sympathy of equilibrium, the action of the internal parts being increased by the speedy application of cold to the surface; and, therefore, if the internal parts be inflamed, their morbid action must be still farther increased. If the cold be long applied, to any considerable degree, it will likewise, by the sympathy of association, weaken the whole system too much, and injure the act of restoration. As bleeding is to be used only until it restores a natural state, and abates pain, so also is cold only to be applied in such a degree as may be necessary for diminishing the preternatural heat, and sensation of the surface; which it does, by lessening the morbidly increased action, and reducing it to the natural state. The degree must therefore gradually be diminished, in proportion as the general disease subsides, otherwise we injure the system, and prevent recovery. There is, however, this difference betwixt bleeding and the application of cold, that the first may be used suddenly, and to a considerable extent at once, whereas, the second ought, especially in all cases of internal inflammation, to be employed more slowly, and its degree regulated by the degree of the general heat of the surface.

Nauseating medicines are also very useful, independently of the sweating which they frequently induce; and are a very powerful mean of abating action in general[5]. Employed, after bleeding has been used once or twice, they are productive of considerable benefit; but there are some affections, in which they cannot be used, such as inflammation of the stomach and intestines; but in inflammation of the lungs, of the throat, muscles, or surface, they may often be prescribed with benefit. The remedies usually employed for this purpose, are, small doses of emetics, given without drink. It must, however, be remembered, that these frequently produce considerable evacuations, either from the skin or bowels, and, therefore, may occasion a permanent weakness. We must likewise avoid raising the sickness to a great degree, and keeping it long up; because the same objection applies nearly to this as to bleeding ad deliquium.

[5] Nausea has often been employed with success, in checking active hemorrhage.

Purging is frequently employed in the cure of inflammation, especially such purgatives as are called cooling, which, in this case, is an imaginary quality; but, unless in so far as they tend to abate the irritation of costiveness, they can do no more than bleeding can, and are, in many respects, inferior to it. They are, in one view, to be compared with the application of cold, which is only indicated when there is much heat; both are intended to diminish action, chiefly by removing stimuli from the part to which they are applied. Purging is very uncertain in the effects which it produces on the system, and in the degree of weakness which it causes; and, therefore, never can be put in competition with bleeding, as a general remedy; and, wherever bleeding is improper, or its propriety doubtful, purgatives are still more injurious. They operate likewise so slowly, at least comparatively speaking, that they do not influence the local action so much, as the loss of such a quantity of blood, as would produce an equal effect on the body, will do, unless in particular cases, when they act upon the principle of the sympathy of equilibrium; as, for instance, in pulmonic inflammation, when they sometimes are of service, by increasing the action of the intestines, and diminishing that of the lungs[6]. In the same way, emetics sometimes cure slight inflammation of the tonsils. One of the best and pleasantest saline purgatives, is the phosphate of soda, which may be given to an adult in the dose of an ounce, in order to obviate the effects of costiveness. If we wish to use it, upon the principle of the sympathy of equilibrium, we must give two ounces, or more. The same cautions which were given, with regard to bleeding, apply also to purging.

[6] This action is, in this respect, similar to that of blisters.

Sweating, considered as a mean of abating general action, is, in most cases, inferior to bleeding; and can never, when the general inflammatory action is considerable, be trusted to alone; but, after the use of the lancet, it is generally serviceable. It is useful, in particular, when the local disease is not confined to a small spot, but affects a considerable surface, or different parts of the body; as, for instance, in the rheumatism; but it acts, in these cases, rather by the sympathy of equilibrium, than by any other mode. At the same time, the induction of a sweat, preceded by bleeding, (which tends to abate the local action as well as the general one) will sometimes be useful, by giving a secretory termination to the general disease, and hastening its conclusion. In the first point of view, sweating may be used early in the disease, especially if preceded by bleeding. In the second, it will be chiefly useful toward the end, as it will then accelerate the termination, and thus influence the local action; for the abatement of the general action must also produce an abatement of the action of a particular part. Sweating, as well as purging, must be used with caution in weakly people, or in those who are reduced by disease; because, although the action of particular parts may be increased by it, yet, partly in consequence of this temporary increase, and partly on account of the fluid which is discharged, general weakness is induced. One of the best sudorifics is the pulvis ipecacuanhæ comp.; of which we may give ten grains every hour, until sweating be produced, giving warm lemonade alongst with it. The tartar emetic is also a very useful sudorific; the sixth part of a grain may be given every half hour, until the proper effect be produced[7].

[7] One grain of emetic tartar may be dissolved in five ounces of saline julep, and a table spoonful given every half hour, as long as may be necessary.

Some of the agentes dissimiles may be considered as proper remedies in this complaint; such as, digitalis, laurel water, lead, &c.; But they are certainly inferior to blood-letting; and have been so little employed in this way, that their effects are not ascertained[8].

[8] Some of these agents might perhaps only change the nature of the inflammation, and render it specific.

Bleeding, of all the general remedies, is the best; and, next to that, cold, and nausea, which may be considered as useful adjuvants. Sweating and purging are mostly to be used when particular indications present themselves, as may be understood from what has been already said. The first of these remedies, act chiefly by producing an universal abatement of action; and, of these, bleeding produces the most permanent effect on the body, and the most certain effect on the local disease. The two last are perhaps more useful, upon the principle of the sympathy of equilibrium, than that of abating action in general, which is only a secondary operation; and, therefore, they may be considered as remedies, acting rather topically than generally; for, according to this view, they act chiefly on the affected part. These two kinds of remedies may, in many cases, be usefully conjoined, producing thus a greater effect than either would do singly.

Before quitting this subject, it may not be improper to attend to the proposal which has been made, of exhibiting anodynes immediately after bleeding, in order to remove the pain. “The most effectual remedy for this purpose, (says Mr. Bell) is opium, which, when pain and irritation are considerable, as in extensive inflammations very frequently happens, should never be omitted. In large wounds, especially after amputations, and other capital operations, in punctures of all kinds too, large doses of opium are always attended with remarkably good effects. In all such cases, however, opium, in order to have a proper influence, should, as we have observed, be administered in full doses, otherwise, instead of proving serviceable, it seems rather to have the contrary effect; a circumstance which is perhaps the chief reason why opiates in general have been very unjustly condemned, in every case of inflammation.” That, in every case of inflammation, opiates are hurtful, is what no one can assert; and their utility will afterwards be fully manifested. But, that opium is useful, or even harmless, in the inflammatio valida, which we are at present considering, cannot be admitted; because daily experience, independent of every theory, proves, that, by their use, the general fever is increased, and the local action aggravated. Even given as a preventative of inflammation, after operations, anodynes are almost uniformly hurtful[9], producing restlessness, heat, and thirst, and afterwards head-ache, sickness, and frequently troublesome vomiting. I have therefore now, after almost every operation, laid aside their use, and find, that the diseased action[10], subsequent to the local irritation, runs its progress with much less disturbance, and is much milder, and shorter, than where anodynes have been administered; and, in general, the sleep is much more composed, and always more refreshing. I have therefore, after lithotomy, amputation, the extirpation of the mammæ, and after labours, in almost every instance, omitted them.

[9] Opiates may indeed abate the smarting, or soreness, which is consequent to the immediate mechanical injury of wounds, or operations; but this relief is commonly only temporary; for the general action is very apt to be afterwards increased, and, consequently, union by adhesion is less likely to take place.

[10] There are two general diseases which are connected with local actions, and which opium is supposed to cure, or prevent from taking place; the inflammatory fever, dependent on an wound, and the febrile state, consequent to a temporary increased action, or exertion of a particular part, or the whole of the system; as, for instance, the effect of parturition. The first of these is always aggravated by opium; the second, if it be not increased, cannot possibly be cured by it.

The local applications are such as tend either simply to abate action in the part, or such as tend to change its nature, by exciting a specific change, or such as act in both ways. The first comprehends cold, the second the agentes dissimiles, and the third topical bleeding.

Cold, applied directly to the inflamed part, is a most useful remedy, diminishing the action to a natural state; but, for this purpose, it must not be applied in too great a degree, otherwise we diminish the action so much, and so suddenly, (and, consequently, the power of the part) that recovery cannot take place. If we apply much cold to a healthy part, we sink its action so far, that it is irrecoverable; if we apply cold to an inflamed part, so as to diminish its action equally suddenly, and in the same proportion, we produce the same effect. Poultices of ice, or snow, are therefore highly dangerous; and even water, although it cannot be made nearly so cold as these. The same direction which has been given, with regard to the application of cold as a general remedy, ought also to be remembered, when we use it as a local application, namely, it ought to be carried just to such a degree, as shall diminish the morbid sensation, and ought to be so adjusted, as to keep the part nearly in its natural degree, or at least very little lower. For this purpose, it must be applied in moderation, repeatedly, and with assiduity; and not, as is commonly done, in a considerable degree at once, and renewed only at long intervals. Cold has been supposed to be useful as an active astringent, producing a contraction in the vessels; but it does not seem to possess any active power in producing such a state in the vessels to which it is applied. Where injury is taking place, from excessive action, cold, by abating it, may strengthen, and produce more natural contractions; but, when applied to a healthy part, it diminishes the action of that part, the blood is less forcibly circulated, and the part shrinks; it therefore stops active hemorrhage in the part on which it acts. When cold is applied suddenly, or to delicate parts, it excites an universal action, or contraction, or shrinking, from weakness; and, therefore, may likewise stop hemorrhage from distant parts. In many cases, when this shrinking, or temporary contraction, is suddenly induced by cold, it becomes converted into the natural muscular contraction of the part; thus, for instance, if cold be applied to the uterus itself[11], when torpid, after delivery, we find, that, after the first effect, or shrinking of the vessels, a more natural contraction takes place. If, however, cold be long applied, we find, that the contraction thus induced ceases, owing to the diminution of action which is occasioned by its continuance, and the original state of collapse, or shrinking, alone remains.

[11] When applied to the skin of the abdomen, it acts chiefly by exciting action, on the principle of the sympathy of equilibrium.

Blisters likewise act by simply abating the action of the part; but differ from cold, in requiring to be applied, not to the part which is affected, but to some other, with which it exhibits the sympathy of equilibrium; as, for instance, to the integuments of the thorax, in pulmonic inflammation; to the skin of the knee, in affections of the joint, &c. It is, however, necessary, when a general disease, or fever, is induced, that bleeding be fully employed, before we have recourse to blistering; because, if it be not, the inflammation, excited by the blister, co-operates to increase the fever, alongst with the original disease, which it has not had time to overcome, or lessen. Blistering likewise acts more effectually, when the local action has been already diminished, by previous bleeding. The size of the blister should be proportioned to the probable extent of the diseased action; at the same time, we must set bounds to this magnitude; because, if too large, they may not only produce, or keep up a general disease, but also, by lessening the action of the internal parts too much, and too quickly, they may prevent recovery[12]. It is therefore better to apply them of a moderate size, and renew them frequently, than to apply one too large at once. It must, however, be remembered, that inflammations of every part are not equally readily overcome in this way; and, therefore, one will require a larger blister than another; thus, the same quantity of inflammatory action in the brain, will be more difficultly subdued, than in the breast; and, therefore, we must apply, in that case, a larger blister. As it is the inflammatory action, induced by the blister, and not the discharge, as was once supposed, which is useful, it follows, that the same blistered place should not be kept too long from healing, or in the state of an issue, but that we ought rather to apply a succession of blisters; and this succession should be pretty rapid. There is indeed one case, in which issues are admissible, namely, where, from the nature of the inflamed part, or the peculiarity of the inflammation, if it be specific, or scrophulous, the progress of the action is very slow. In these cases, a rapid, and continued succession of blister would, doubtless, be most useful, but, from the duration of the treatment, would scarcely be submitted to: Issues, which are less painful, and less troublesome, are, therefore, generally preferred. We have an instance of this in many diseased joints.

[12] Were this not the case, we should cure pulmonic inflammation, with the greatest certainty, by covering the whole thorax with a blister.

The remedies which tend to diminish the inflammatory action, by producing a peculiar, or specific change, are, the agentes dissimiles, of which, for this purpose, lead is the best, and the one which is most frequently employed. Lead, in the state of an oxyde, was long ago used; but it does not appear, in this condition, to have much activity; and, therefore, the saline preparations are now introduced into use. The acetite of lead, on account of the supposed power of vegetable acids in abating inflammation, has been considered as possessing a great superiority over other forms; but its chief recommendation over other soluble preparations, is its cheapness; for the nitrate of lead seems to be equally powerful. The acetite of lead may be employed, either before or after crystallisation; but, if we use the crystals, they must be redissolved; for which purpose, soft, or distilled water, must be employed, otherwise a decomposition takes place. The strength of the solution which we apply, must be determined by the natural delicacy of the part, and its morbid sensibility, in consequence of inflammation. In the inflammatio valida, in which alone it is proper, the solution never ought to be so strong as to produce pain. When the eye, urethra, and other delicate parts, are inflamed, the application ought to be just so strong as to produce sensation, and should be very frequently repeated. When the cellular substance is inflamed, and we begin the application before the cutis be much affected, the solution will not require to be so strong as to produce sensation; because, were it to be so, the action excited might, from the quantity required to produce the effect, be so great, and so suddenly induced, that the powers of recovery would be lost, or a specific inflammation be occasioned, as we observe, when the solution is very much concentrated, in which case, even sloughs are sometimes produced. On the same account, we must renew the application frequently, at least if we use pledgets, otherwise the evaporation of the solvent increases the strength more than we desire. For incipient phlegmon, we may employ a solution consisting of three pounds of rain or river water, and five drachms of sugar of lead; or the following, which is more elegant:

R. Cerussa Acetatæ dr. iii ss. Aceti Vini unc. iii. Solve super focum dein adde. Aq. Distill. Frigid, lb. i ss. Aq. Rosar. unc. iv.

This may be applied by means of pledgets of linen; or part of it may be made into a poultice, with crum of stale bread.

Saturnine poultices ought always to be applied cold; because we thus receive both the benefit of the cold, and of the lead. The directions which have already been given, with regard to the application of cold, are to be attended to here.

Lead has been supposed to act as an astringent; but, if astringents were useful, alum would be more effectual than any of the preparations of lead.

The vegetable acids have been considered as sedatives, and are generally employed in the cure of inflammation; but it would rather seem, as if they belonged to the class of agentes similes; for, in moderate quantities, they increase the appetite, &c. which no sedative, or agens dissimilis, ever does[13]: They also excite a general action, which is different from that induced by sedatives, and which is useful in curing many of the actions induced by these agents. We likewise find, that they are not serviceable, as local applications, in the cure of inflammation, unless in so far as they become the vehicle for applying cold. The surface is not very susceptible of their action; and, therefore, those who are inclined to continue their use, may do so without injury, and even with benefit, if they be cold; but then the same benefit will be derived from cold water.

[13] Like other agents of this kind, they may kill speedily, if drunk in too great quantities; and, after death, the vitality, from the previous great action, is found completely destroyed.

Alcohol is likewise considered by some as a sedative, and introduced as a remedy, in the enumeration of those which are applicable in inflammation[14]; but, whatever its use may be in the inflammatio debilis, it must be allowed to be evidently hurtful in the inflammatio valida.

[14] Hunter on Inflammation, p. 350.