Part 2

The circumstance of being in an unusual situation, in which the natural action cannot possibly be continued, is also a very frequent cause, producing inflammation, and preventing its resolution. We ought, upon this principle, which has been formerly mentioned, to endeavour, in almost every instance, to bring the sides of the wound together, if an wound has been the exciting cause of inflammation, by which we shall much more readily prevent or overcome the inflammatory action; because we thus bring the parts nearly to their natural situation, with respect to interstice, and thus make the organic particles be more readily thrown out. This practice ought to be pushed farther than is often done. Even in many contused wounds it will be useful; because, although union may not be immediately produced, yet, when the contused part is either recovered, or absorbed, the inflammatory action may be prevented, or removed, by the restoration of the natural action, if the part be in absolute contact. It must, however, be remembered, that if much difficulty be experienced in bringing and retaining the parts together, owing to the swelling, from the previous existence of the diseased action, then our endeavour will be hurtful; because the irritation which we thus give, has a greater power to increase the action, than the circumstance of the parts being in contact, has to diminish the inflammation, and restore the natural action.

Bringing two surfaces in contact, although they naturally were not so, will have the same effect. Thus, if the skin be taken off the edges of our fingers, and the side of the one be applied to the side of the other, adhesion will take place, and no inflammation will be produced. When a part is inflamed, and one portion is brought in contact with another, we uniformly find, that the inflammation is less where the parts were in contact than elsewhere. Thus, when the intestines are inflamed, the parts suffer least which touch other intestines, whilst the angle betwixt the folds is most affected. This fact is observed by Mr. Hunter, but explained upon the principle of contiguous sympathy; or, “a mutual harmony being produced, which prevents their being inflamed.”

By removing, then, the exciting causes of inflammation, before the action be induced, we shall frequently prevent it altogether from being formed; but, even although we should be disappointed, we, by this removal, render the disease milder, less extensive, and much more easily overcome; for, as long as the exciting causes continue to operate, it is impossible to procure resolution; but the action will be kept up until some other termination, or consequence, be induced. But, although we thus prevent the action from being raised to so great a degree as it otherwise would be, yet we do not immediately overcome or destroy it; because the action, when once induced, has, like every other action, a tendency to continue for some time after its cause is withdrawn. This continuance may be longer or shorter, according to circumstances, and its termination may be more or less unfavourable. We are, therefore, under the necessity of employing such remedies as have a power of directly diminishing or removing this action. It has, however, been doubted, whether they ought, in every instance, to be employed; or, in other words, whether resolution ought uniformly to be desired. It has, for instance, been deemed unsafe to check those inflammations which depended upon a general or constitutional specific disease, or occurred during its existence. But this opinion, which was evidently founded upon the supposition of the operation of morbid humours, cannot be maintained, now that this is given up. Granting inflammation, in every one of these cases, to be dependent upon the general disease, and to exist as a symptom of it, no harm can accrue from resolving it; because, if the inflammation have once taken place, the full effect of the general disease is produced, which, therefore, cannot be affected by the peculiarity of the termination of this inflammation, unless it be proved, that some humour be sent there to be concocted and thrown out. In many instances, inflammation occurs in a general disease, merely as an accidental circumstance; but, even in those cases where the local inflammation is most decidedly dependent on the general action, and is perhaps essential to it, we find, that no bad effects follow from resolving the inflammation; and, if this be the case with regard to specific inflammation, we may still more certainly extend the principle to the treatment of the simple inflammatory action, with which we have at present a more immediate connection. There are, however, some inflammatory affections which we sometimes cannot put back; such as those tumors which succeed the small-pox; but, when we do succeed, no bad consequence follows; and the failure of some of our attempts can be no argument against the general plan, more than our failure in many other instances.

If we attempt, without fear, to cure the general disease, why may we not also endeavour to hasten the termination of the local disease?

Resolution is the quickest termination of inflammation, and, therefore, ought, perhaps in every instance, to be attempted, unless in cases where the injury is such that suppuration is unavoidable; as, for instance, extensive bruises, &c. It is our great object, even in those inflammations which we raise intentionally; as, for instance, in the operation for hydrocele. At one time, however, this was not admitted without limitation; and suppuration was, in many instances, anxiously sought for, being considered by some as the only way of obtaining a cure. “Union, (says Mr. O’Halloran) without suppuration, by an immediate coalescence, or by the first intention, is merely chimerical, and is opposite to the rules of nature. Inflammation (contrary to the received canon) is not the time for a reunion of divided parts: This happy minute follows, not precedes suppuration.” It was timidity, with regard to the prevention of suppuration, and want of knowledge of the powers of the animal frame, which so long retarded the progress of surgery, and prevented the improvement of its operations.

The remedies which we employ, with the intention of abating and removing the inflammatory action, are either general or topical.

General remedies are perhaps only useful, or have only a superiority over topical ones, when a general disease, or fever, accompanies the local inflammation. Topical ones are only to be trusted to alone, when the disease is entirely local.

The general remedies, are naturally such as tend to abate action in general, or to diminish the natural action; and, therefore, will consist of bleeding, cold, purging, sweating, nauseating medicines, and some of the agentes dissimiles.

Bleeding is justly considered as the most powerful, and the most useful of all those remedies; and, in many cases, is the only one which can accomplish a cure. The quantity of blood which it is necessary to detract, will be regulated by the effect of the inflammation upon the system, and by the previous condition of the person, with regard to strength; for those who are weak bear bleeding worst; and in them we cannot repeat it so frequently, as in the robust. Delay in them is, however, more dangerous; because the inflammation makes a more rapid progress, and, therefore, we ought sooner to push our remedies.

When the system is affected, in consequence of inflammation of vital parts, the general action is greater than when other parts are affected, and, therefore, bleeding must be used earlier, and with more freedom. Mr. Hunter observes, that when these parts are inflamed, the patient bears bleeding worse than when parts are affected which are not vital; but this observation must not be admitted indefinitely. When these parts are affected, the action is so violent, that the power cannot long support it; and, therefore, we must have early recourse to the lancet, and allow the blood to flow until the pain diminishes, and ceases to abate any more, and until the pulse becomes softer, and perhaps fuller. This is the time to stop; but, whenever the pain returns, or the pulse becomes hard, the orifice should be again opened, although we had bled only half an hour before. The system, in this way, is not weakened, nor the action sunk so low as to injure the power of recovery, which might be the case, were we to bleed too copiously at once. This remark applies, in a particular degree, to inflammation of the bowels; but it may also be extended to pulmonic inflammation; only, in this case, we can detract more blood at a time than in the other instance; because the system sympathises less strongly with the lungs, and, therefore, general evacuation will be longer of operating on the local disease. The same cause, however, makes the danger less; because the general action is not raised so high, and the part itself not being so delicate, can support the action longer, and, consequently, the danger is less. It is an established point, that no action can subside, or be destroyed suddenly, and the patient become free from disease. All morbid actions must subside, more or less slowly, and, therefore, bleeding ought not at once to be pushed so far as to produce fainting, unless the patient be very liable to faint. This sudden cessation of general action does not destroy the specific nature of the action which is going on when it is induced, but rather leaves the parts stationary, the tendency to morbid action still continuing, although the capability to act be suspended for a moment. In place, then, of bleeding so as to exhaust the strength quickly, and endeavour, as it were, by the quantity of the discharge, to destroy the disease by one bleeding, it will be much better to bleed just until we produce the feeling of weakness to a moderate extent, and abate, to a certain degree, the pain and hardness of the pulse; stopping, whenever we find that we are not abating it farther, distinguishing, however, betwixt real abatement and syncope, or want of power to act and feel. We then repeat the evacuation, whenever the hardness of the pulse and pain return; and thus, perhaps in one day, and with infinitely more benefit, bleed much more frequently, and, perhaps, to a greater extent than is sometimes done in a week, by those who bleed more copiously at once, and repeat it seldomer.

When we are obliged to stop our bleeding, on account of fainting, before we would otherwise do it, we will find it necessary to repeat the venesection sooner than if this did not happen.

Concerning the exact quantity of blood, which ought, in the different varieties of inflammation, to be detracted, I hold it, from the above principle, to be ridiculous to give any direction; because no general rule can be given, by which we may, a priori, determine the quantity. We are to bleed until we procure an abatement of the action; and to stop whenever this abatement ceases to be really progressive. We are to renew the bleeding, whenever the action again increases, and stop, as before, whenever it is abated, remembering, that, after some time, a more sparing detraction will produce a greater effect, than a more copious one would do, in the commencement of the disease. It must also be attended to, that, owing to the weakness induced by the disease, and by the bleedings, we must, toward the end, bleed at longer intervals; for, if we continue to bleed in the same way as formerly, we would either kill the patient, or at least prevent the act of restoration from taking place; because we would thus diminish the power, or vital energy, which was to perform this act. Those, then, who order a certain number of ounces to be taken away, must reason upon probability, and prescribe less efficaciously, than those who direct no determinate quantity, but regulate their practice by the effects. It is equally foolish in those who order bleeding, pro viribus, and are satisfied with this until their next stated visit; because bleeding until fainting takes place, and not repeating it for some time afterwards, may be doing a great deal too little.

We must distinguish, as has been already mentioned, betwixt a real abatement of the inflammatory action, and a mere temporary suspension of action, or syncope.

As there is a proper time for stopping each individual evacuation, so also is there a period at which we ought to stop the general plan of cure by bleeding, or at least to intermit it. And to determine when this period is come, is sometimes a pretty nice point, and one of much importance; because, if we stop too soon, we allow the action still to go on, and, perhaps, to terminate fatally. On the other hand, if we bleed too long, we sink the parts below the state necessary for recovery, and even accelerate the unfavourable termination. When, for instance, from the state of the pulse, and other circumstances, we apprehend the accession of gangrene, bleeding will not abate pain, but will bring on the mortification sooner, and make it spread farther, as will be afterwards mentioned.

As the accession of inflammation depends upon a change of the natural action of the vital principle, so does its removal depend upon the reconversion of this into the natural action, which implies activity, or an active state. If, then, we bleed in the end of inflammation, we lessen the powers of the part so much, as to prevent restoration; gangrene, therefore, will take place: Or, if the part be less delicate, and the progress of the action consequently slower, the inflammation may continue stationary for a considerable time, and become chronic, or habitual. This state is not to be cured by bleeding, but will rather be made worse by it. Whenever, then, after inflammation has continued for a length of time, we find, that venesection does not produce the usual abatement; or, whenever, although there be a temporary abatement, the pain increases afterwards to a greater degree, we may be certain our treatment is improper. We likewise find, that the longer bleeding has been delayed, in the beginning of the disease, the sooner must we stop, and the less quantity must we take at a time; because, in this case, the inflammatory action is nearer its termination, and is more ready to produce gangrene, if the parts be delicate, or the action great, or, if otherwise, the inflammatio assuefacta. We are also to refrain from bleeding, when we find that the inflammatory action is about to terminate in another action; as, for instance, the suppurative; because, in the first place, bleeding, in this new action, can do no good, but, by weakening, will do harm; and, secondly, if there be only a tendency to this action, the action not being yet formed, or beginning to form, we may, by bleeding, interrupt the progress of the inflammation, and convert it into a more tedious disease, or the inflammatio assuefacta.

Bleeding has been used, not only as a cure for inflammation, but also as a preventative; but this must be considered as proper, only in particular instances. When, for instance, an wound has been inflicted, or an operation necessarily performed, on a robust person, bleeding immediately, or very soon after it, may be useful; because it will tend to lessen the chance of the natural action being carried so high as to become changed. These people cannot have their action much increased without disease; and, therefore, it is necessary to lessen it, and bring it down to a more proper medium. But there are other cases, where the action is naturally rather too low, and the patient weakly. In these cases, bleeding can do no good, but much harm; because it increases the previous weakness, and makes the inflammation, if it does occur, more dangerous, on account of the little power which there is to support the action. These people even bear bleeding worse than others, when inflammation has actually taken place. It ought never to be practised, in order to reduce the natural action, before disease has taken place; and, after the inflammatory action is induced, it ought to be used cautiously, and only to such an extent, as may be necessary for removing the tendency to immediate bad consequences. It ought, however, to be used very early in the disease; because, in weak people, the action does more harm in a given time, than in the strong; but it ought likewise to be sooner abandoned, otherwise we either hasten mortification, or prevent the act of restoration from taking place.

Bleeding is rarely necessary in inflammation of the cellular substance alone, unless the action be extensive; in which case, the system is so affected, as to require our interference. When the cutis is inflamed, producing erysipelas, the system suffers considerably; but, as this frequently ends in mortification, bleeding has been neglected by many; but it is evident, that, if the disease be simple, and not dependent upon any specific agens dissimilis, or epidemic contagion, venesection is the proper cure, provided it be early employed, as we thus diminish the action more certainly than by any other means. If, however, the disease have been neglected, and the action be nearer a termination, then we must either do nothing in the way of general treatment, or must give opposite remedies from bleeding, according to circumstances. When muscles are inflamed, bleeding is often necessary to a very great extent, as we observe in rheumatism; and, in the beginning, we must take a greater quantity at a time, in order to procure an abatement, than in many other cases. When the viscera are inflamed, bleeding is uniformly necessary, and generally requires to be frequently repeated.

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. 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.

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. 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.

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.

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.

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