Part 3

The last division of local application, contains those which tend, both simply to abate action in general, and also to excite, to a certain degree, a specific change of the action. Topical bleeding is the chief remedy belonging to this division. Bleeding with leeches, or the scarificator, is employed in two different circumstances: First, when we detract directly from the inflamed part; as, for instance, from the surface of a phlegmon: Secondly, when we detract only from the neighbourhood of the inflamed part; for instance, from the skin which covers an inflamed joint. When we employ topical bleeding, in the first case, we may suppose, that the aperture, and effusion from the extremities of the inflamed vessels, produces, to a certain degree, a change of action. Every action of the vessels is performed at their extremities, and the trunks and branches may be considered as canals subservient to the extremities, and which contract and dilate, in a degree proportioned to the general and local action. If, during health, we open a number of the extremities of these vessels, we induce the hemorrhagic action, which continues longer or shorter, according to circumstances, and which gradually terminates in a serous discharge, or secretion. If, during inflammation, we open a number of the extremities of vessels, either in the inflamed part, or immediately contiguous to it, we induce a similar hemorrhagic action, which is different from the inflammatory one, and, therefore, tends to diminish that action in the part. We likewise, by inducing the serous secretion, tend to produce a termination to the inflammatory action.

Topical bleeding will also, in part, operate, by simply abating the action, in consequence of the mere loss of blood; for, as the blood is withdrawn immediately, by different orifices, from the vessels of one part, that part, and those near it, may be supposed to suffer sooner, and to a greater degree, than the rest of the system. The branches which yield the blood, will even suffer considerably, for a time, although the loss of blood be very trifling, and produce no effect on the system. Thus, if one small artery be divided, we find, that, although the quantity of blood which flows from it be very inconsiderable, yet it is sufficient to produce evident changes in that vessel, making it contract, and become smaller, although the vessels in other parts be not at all affected. This depends upon the peculiar[15] action of the individual artery being affected[16], and the contracting state of the orifice, spreading along the branch and trunk by degrees[17], by which less blood is made to circulate through it. Bleeding from a vein, however, has not the same effect; because the quantity of blood in a part, is not so immediately dependent upon the state of the veins; and because veins are not the seat of much action. When we divide a small vein, we find, that it, by degrees, contracts, and transmits less blood, or closes completely; but the blood from the part does not circulate faster, nor is less blood sent to that part than formerly; therefore, topical bleeding from veins near the affected part, can have no great superiority over general bleeding.

[15] By peculiar action, I do not here mean what is commonly understood by the term specific, but the action which is proper to the artery, considered as an individual, in opposition to the action of the heart and arteries, considered in general as an entire circulating system; for one part of this system may act less powerfully than another, and may be more dilated, &c.

[16] The distance to which this will extend, depends chiefly upon the quantity of blood which is lost, and the size of the vessel which is affected.

[17] This depends upon the operation of the sympathy of association. Sympathy was, in the preliminary dissertation, divided into that of association, and that of equilibrium; and it was mentioned, that the same parts might be made to exhibit either of these, but that naturally the sympathy of association is chiefly, and most easily exhibited by those parts which are similar in structure, and contiguous to each other; and, in them, the action spreads fastest. At the same time, if the action continues long, or be very strong, it may be propagated to dissimilar parts, and produce either a very extensive, or an universal action, which is just a greater degree of the sympathy of association. In this case, it has, however, been called universal sympathy.

The division, then, of a number of small arteries, may cure inflammation in two ways; first, by inducing a different action; secondly, by possessing the general properties of bleeding, namely, a simple diminution of action. The first will operate chiefly, when we apply the leeches on part of the inflamed portion. The second will operate, when we detract only from the immediate vicinity; and, in this case, the quantity of blood which is taken away, must be greater; because the effect has to be extended some way, the vessels not being in the inflamed part. The quantity must likewise be greater, because the effect depends entirely upon this; whereas, in the other case, it depended, in part, upon the peculiarity of the action which was produced.

The number of leeches which it is necessary to apply, will depend upon the violence of the action, and the place on which they are set; for, the greater the distance from the inflamed part, the more numerous ought they to be. It is therefore impossible to give any particular rule for the extent of topical bleeding. It may, however, be proper to observe, that we ought not to be satisfied with one application, more than with one venesection, for a general disease, but ought to repeat the local bleeding, whenever it may be necessary, although it may be twice or thrice in a day, founding our indications upon the same principle on which we use general bleeding. It is by a too sparing application of leeches, and their not being repeated sufficiently frequently, that we so often fail in removing inflammations, which, by a more active treatment, we might resolve. In general, the leeches ought to be applied as near the affected part as possible, or upon it. If, however, the seat of the inflammation be chiefly in the cutis, as in erysipelas, it will perhaps be more prudent not to apply them upon the spot; because the subsequent irritation is apt to increase the action afterwards, on account of the great delicacy of the part. There may even be some doubt as to the propriety of applying leeches to the vicinity of the inflammation; for the irritation of the bites may produce erysipelas in the part, or cause the original disease to spread.

The scarificator may be used where leeches cannot be obtained; but it is not so useful, when applied to the inflamed part, on account of the irritation which attends its application, and the cupping; but it is equally proper, where we detract not from the part itself, but from its vicinity.

Of the topical remedies, bleeding is the most powerful; and, next to that, cold solutions of lead. Where these cannot be employed, owing to the internal situation of the inflamed part, blisters must be used in their place.

Many other remedies used to be recommended, under the name of discutients, repellants, &c.; some of which have been formerly mentioned, when considering the ancient theories of inflammation; these, however, are now laid aside. But many practitioners still have an idea, that benefit will be derived from mechanically softening the parts by means of oils, or what they call emollients; and seem to consider, that poultices are chiefly useful for the same purpose; at least they only direct, that they shall be removed before they turn “stiff or hard.” But inflammation must be attributed to a different cause than increased attrition, and its cure must be effected by different agents from those which we employ for softening a piece of dead skin. Oils and liniments, in so far as they form a basis for other applications, or are used alongst with gentle friction, may be occasionally proper in the inflammatio assuefacta; but, in the inflammatio valida, they must be considered as absolutely useless.

There are also some remedies, recommended with the intention of absorbing acrimonious excretions; such as, flour or magnesia, in erysipelas. But these seem to act entirely by allowing the action to run its course, without interruption, affording a softer defence than could otherwise be obtained. From the quick progress of violent cuticular inflammation, the applications which are usually made in other inflammations have been forbid here, and are said to be pernicious; but this rather appears to arise from the application not being properly timed, than from any peculiarity in the disease. It is not easy to give any good reason why cold saturnine solution, of a proper weakness[18], and sufficiently early applied, should not be useful; nor do we find, that they are in reality hurtful in simple erythema. Where this, however, attends wounds, or is not an original disease, these are improper; because it is in general, in these cases, an attendant upon the inflammatio debilis, or a symptom of it, and requires either to be let alone, or to have stimulating applications made to it, at the same time that we give bark internally[19].

[18] The solution must, upon the principles already laid down, be both weak, and only so cold as to reduce the sensation of the part to its natural condition, that is to say, so as to abate the morbid feeling of heat; because, if we make it otherwise, we may injure the powers of recovery, and perhaps induce gangrene. The application ought not to be so cold as to excite the sensation of coldness, at least in any considerable degree.

[19] Bark is useful and necessary in every case of erysipelas, after the inflammatio valida has abated. Local applications, of a stimulating nature, are also useful at this period, as will afterwards be mentioned, when the inflammatio debilis comes to be considered.

These remarks upon the resolution of the inflammatio valida, may be concluded, by observing, that the diet ought to be low and sparing, in a degree proportioned to the violence of the action. Such motion as affects the local action, must at all times be prevented; but when a general action likewise exists, then general quietude must also be insisted on.

_Of the Remedies which are necessary for inducing Suppuration._

Suppuration is a new action, the exciting cause of which is inflammation; but, that it may take place, it is requisite, that the inflammatory action be prevented from subsiding too soon, or too suddenly; in which case, either resolution, or inflammatio assuefacta, takes place: Whilst, on the other hand, we must prevent the action from rising too high, and proceeding too rapidly; in which case, mortification is caused.

In these cases, in which resolution cannot be obtained, suppuration will generally take place, without any interference on our part, provided we prevent the action from terminating in gangrene. This we observe in many internal inflammations. At the same time, we may sometimes accelerate this process, by a proper regulation of the original action.

The remedies proper for moderating and removing the inflammatory action, have been already mentioned; but these sometimes fail to produce resolution; in which case, either suppuration, or mortification, take place. When the symptoms of suppuration take place (which have been already noticed), all that is perhaps essentially necessary, is, to give up the resolving plan, and not interrupt the natural progress of the action. If, however, the inflammatory action continue longer stationary, and seem neither to be resolving, nor decidedly inducing the suppurative action, then such remedies as increase the action, and accelerate its progress, are essentially requisite. These remedies, however, are, in general, indiscriminately applied in both cases.

For the purpose of inducing, or accelerating the suppurative action, it was formerly the practice to apply liniments, cataplasms, and fomentations, composed of stimulating substances, such as garlic, turpentine, galbanum, &c.; but of late these have been almost entirely abandoned. Heat and electricity have the property of increasing the performance of every action which is existing at the time of their application, and, therefore, are the remedies chiefly to be employed in the present instance.

Heat may be applied in two ways, with or without moisture. In the first, it increases action more suddenly, and perhaps more simply. In the second, its effects are more gradual, and are likewise complicated with those of moisture, which certainly is an agent capable of operating on the living system, and generally tends to excite a secretory action, or to give a secretory termination to those increased actions, which are induced by agents operating alongst with it. Dry heat is therefore evidently improper in the inflammatio valida, because it will tend to produce mortification; but, if moisture be conjoined, then the suppurative action is excited. When, however, the action has made an approach to the inflammatio assuefacta, then it may be useful to raise the action simply by dry heat, for a little, before we apply heat and moisture; because, if we apply moisture at first, the progress is more tedious, and the action is less certainly excited[20]. Electricity is similar in its operation to heat and dryness, and may be usefully employed in similar cases; but we must, if we expect any benefit, repeat its operation frequently, and continue each application for a considerable time[21].

[20] From what has been said in the preliminary dissertation, we may understand how moisture should tend to induce a secretion. Agents frequently excite conditions somewhat similar to their general properties: Thus, putrid matter tends to induce the action of descent, and consequent putrefaction. We likewise experimentally find, that, if moisture be applied during a general increased action, it induces perspiration, unless it be conjoined with cold, which lessens the action.

[21] The proper way to use electricity, in this case, is to draw scintillæ from the part, the patient being insulated.

There are two forms in which we employ heat and moisture, namely, fomentations and poultices. Fomentations[22] have this superiority over poultices, that the same degree of heat is always kept up during their application; whereas, when we use poultices, the heat subsides, as they are renewed only at considerable intervals; but fomentations require longer attendance, and more trouble; and, therefore, are only employed for a short time, and commonly betwixt the intervals at renewing the poultices.

[22] Fomentations are made, by applying a soft cloth, dipped in any warm fluid, (commonly water) to the part. Sometimes the cloth is wrung hard, in which case it is chiefly steam which is applied.

Poultices are generally made of bread and milk boiled together, so as to form a thick kind of paste, to which is added, so much olive oil as will preserve it from hardening quickly[23]. These ought to be applied, either of the same temperature with the inflamed part, or hotter, according to circumstances. When the inflammation seems to be naturally and quickly tending toward suppuration, it is, as has been already mentioned, by no means essential, that any application be made externally, in order to induce the suppurative action[24]; but still poultices are used, and, in many cases, accelerate the progress. In this case, the poultices should only be applied so hot as not to give any considerable sensation of heat, otherwise we increase the action too much, and too rapidly, and, if early employed, may even interrupt, or stop the incipient purulent action, renewing the inflammation, and perhaps making it terminate in partial gangrene. Poultices, then, should not be applied very hot at first, especially when the action seems to be such as to make us expect that it shall run its course without any assistance. But when the inflammatory action has been more tedious, and does not terminate in the suppurative one so soon, and so decidedly as we would wish, then poultices must be applied, with a different intention, being meant, not solely to prevent the action from sinking, as in the first case, but also to raise it, and make it brisker. The heat must therefore be greater, and such as to give a considerable sensation; and the poultices, instead of being changed only when they begin to grow hard[25], which is perhaps all that is necessary in the first case, must be renewed very frequently, in order to keep up the increased degree of heat, or the agent which supports the action, and accelerates its progress. They ought, in this case, to be taken off and warmed, or renewed almost every hour, at least when the action is tedious, that is to say, when they are most required. We are then not to lay down any certain degree of heat which is to be employed, nor fix any particular number of times at which the poultices must, in every instance, be changed, but regulate our practice entirely by the nature of each particular instance, taking the progress and degree of the action as our guide, in this respect, and interfering exactly in proportion to the necessity for interference. It may not, however, be improper to remark, that, cæteris paribus, the heat must be greater in proportion to the depth of the inflamed part below the skin; or, in other words, we must apply more heat, when we are obliged to act on a part not yet inflamed, than when we act directly on the inflamed part itself. When an abscess forms at a distance from the surface, the parts betwixt it and the surface gradually come, as was formerly mentioned, to assume the purulent action; and the sympathy of equilibrium, which naturally exists betwixt the surface and the parts below, gives way to the sympathy of association[26], the parts coming, by degrees, to perform one uniform action together, which spreads from within to without. When we apply heat to the surface, at this place, we, by continuance, likewise induce the sympathy of association, and the increased action spreads and operates on the disease; but there is this difference, that the action of the heat spreads from without to within, and thus accelerates the progress of the suppurative action.

[23] Poultices may also be made, by boiling pounded linseed-cake, or from potatoes, or mashed vegetable leaves (which are the cheapest for hospitals), such as tussilago, &c.

[24] The inflammatory action, when moderately strong, acts naturally as an exciting cause, inducing the purulent action, which is therefore said to be a termination of inflammation. It is therefore as unnecessary to interfere in the production of this secretion, when the action is of proper strength, &c. as it would be to attempt to increase, by local means, the vesication which is produced by a blister. Poultices are, in this condition, perhaps chiefly useful, by removing the causes which tend to abate the action at an improper time, such as those which produce resolution, as cold, &c.

[25] They keep up the heat of the part, and keep it moist until this happens, and prevent the action from flagging suddenly, which is all that is required of them, when the action is going on of itself in a proper degree.

[26] When two parts are affected at the same time, in consequence of an agent operating quickly on one of them, they commonly exhibit the sympathy of association, which takes place suddenly, but generally at first lasts only for a short time, if the parts be distant; but, if the original disease still continue, it may spread, inch by inch, until it arrives at the part which was formerly affected, and which is again affected more permanently, by the same kind of sympathy taking place, but in a different way. In the first case, we have the sympathia consociationis interrupta; in the second, the sympathia consociationis serpens. It is this last which is the cause of the extension of all action in a part, and which, when strongly excited, overcomes the natural tendency to the exhibition of the sympathy of equilibrium. It is, however, more difficult for local action to spread by degrees to parts which evince the sympathy of equilibrium than other parts; and these, in general, are longer of being affected. Thus, when inflammation begins in the skin, it can much more easily spread along the skin than dip down to the muscles.

When the suppurative action has existed a certain time, we find, that it gradually extends itself to the skin, purulent matter being formed, instead of organic particles; on which account, the cavity enlarges, and the covering becomes daily thinner. At last, the action reaches even to the cutis, which becomes white and flaccid, first at a point, and then to a greater extent[27]. When this happens, the thin covering is either torn by the pressure of the contained fluid, acted on by the surrounding parts, or acting by its own weight; or, if this does not take place, the suppurative action still proceeds going through the cutis, the organisation of which, like that of the parts below, is lost: The thin cuticle now rises up into a little blister, and then gives way. The matter runs gradually out, the sides collapse, and come nearer by degrees to each other, at the same time that the ulcerative action succeeds to the suppurative. The quantity of the discharge, therefore, daily lessens; the internal surface, or sides of the abscess, come in contact; and the granulations at the margin or circumference unite; those belonging to one side uniting with those of the other, and thus producing recovery by successive circles of reunion, which form rapidly, or more slowly, according to circumstances.

[27] In proportion as the action extends outward, it also becomes more concentrated. An abscess is therefore somewhat conical, or at least hemispherical, the base being turned inward, and the apex outward. When the action reaches the surface, it is first at a single point; but, by degrees, it becomes extended, and the apex becomes broader.