Part 3

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, 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, 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.

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.

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, 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.

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. 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.

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: 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.

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; but, whatever its use may be in the inflammatio debilis, it must be allowed to be evidently hurtful in the inflammatio valida.

Hunter on Inflammation, p. 350.

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 action of the individual artery being affected, and the contracting state of the orifice, spreading along the branch and trunk by degrees, 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.

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.

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.

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.