Part 4

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, 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.

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.

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. 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.

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.

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 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.

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. 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; 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, 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, 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.

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.

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.

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.

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. 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.

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.

Such is the natural progress of an abscess; but it has been proposed, that it ought not to be allowed to follow this, but ought to be opened before it bursts spontaneously; and this opening has generally been desired to be pretty large, chiefly perhaps on the principle of allowing a free evacuation of the matter. Where abscesses are seated over cavities into which they may burst, instead of opening externally, there can be no doubt of the necessity of making an early evacuation; and, in these cases, we ought to open them before the skin becomes white; or, in other words, before the action reaches the surface; because, if the abscess be seated equally betwixt the skin and the cavity below, we may suppose, that, if it be extending itself in all directions, or toward the cavity, in the same proportion as outwardly, that the parts below will become almost irreparably diseased before it can reach the surface, and will give way afterwards, even although an opening be made externally. Where, from the confinement of the matter, it seems to be spreading, or diffusing itself, by its gravity, through the cellular substance, or among the muscles, it will likewise be necessary to open the abscess early; but, in this case, the abscess is unhealthy; for, were it otherwise, the matter would be confined by the circle of diseased organic matter thrown out during the inflammatory action, and which is only removed gradually. In this case, the suppurative action has extended itself laterally, and perhaps downward, more quickly than in health, and has not observed the same ratio, with regard to the extension toward the surface; the action, therefore, reaches parts which were not formerly inflamed (by the sympathia consociationis serpens), before the surface gives way; and, therefore, the matter spreads or diffuses itself; for, by the spreading of the action, the confining barrier is removed, and the matter mechanically extends itself. This is an unhealthy abscess, and the action is of the phagedenic nature. Opening the abscess will not always stop this morbid action; but, by removing the matter, it will lessen the chance of diffusion. We must, however, continue the free evacuation, and place the member in a proper posture; because, if the action continue, the matter which still is formed will lodge, and form sinuses.

Such as the thorax, trachea, &c. Instances have happened of suffocation being thus produced.

Although, in general, an abscess has little tendency to extend itself deep down, but rather moves toward the surface, although so far from it originally, that, had the action extended equally in all other directions, the size of the abscess must have been immense; yet, when it is situated over a cavity, it may proceed toward that as if to an external surface. Even, however, in this case, the general law, of all actions tending to the skin, obtains; for the progress outward is much quicker than that inward; but, if the action commenced near the surface of the cavity, as is commonly the case, the difference of the distance will compensate for the superior tendency to extend outward; and, therefore, the abscess may burst at the internal surface into the cavity.

In abscesses seated on the thorax, I have known the intercostal muscles and pleura continue the suppurative action, after the external surface had opened, and thus an opening came to be formed into the thorax.

In healthy abscesses, where we do not apprehend any detriment to the neighbouring parts, the question comes to be, whether opening them will accelerate the cure? Perhaps much of the diversity of opinion on this subject, has arisen from not attending to the condition of the abscess which we have been managing, and thus we apply the prognosis and treatment of one kind of abscess to different ones. When an abscess has been formed slowly, and runs its course rather tediously, we may suppose, that the action shall continue for a considerable time without being converted into the ulcerative one; and, therefore, the abscess shall remain long without healing. In this case, a free incision, or the irritation of a foreign body, may excite the ulcerative action, and thus accelerate the cure; for these abscesses have come to approach toward the nature of common encysted tumors, and require the same treatment. But, where abscesses are running their progress with due celerity, and the action is proceeding through its proper course, there is not the same cause for interference. If, in this case, we open them before the action has gained the surface, we derive no benefit; because the action still proceeds, and the same events and circumstances take place as if we had allowed it to burst. If we make a large aperture, when the abscess is ready to burst, we, by the irritation, interfere with the process which was going on, and delay the cure. The admission of the air to the abscess, owing to the free exposure, is one cause of this delay; for it changes the nature of the purulent action, and, if the ulcerative action takes place, frequently renders it unhealthy; the consequence of which, if the abscess be large, or situated in vital parts, is hectic. We likewise, in large abscesses, by the sudden evacuation of the matter, and removal of the distension, sink the action of the parts, and make covery more tedious. When the abscess, then, is healthy, and the action strong, it will be more proper to allow it to follow its natural course, and burst spontaneously, than open it, by a large incision, or by the introduction of a seton: If we do open it, the orifice should not at first be large, but should just comprehend the diseased or whitened surface.

This likewise affects the system, and produces syncope, if the mechanical support be withdrawn suddenly from the parts.

Sometimes, after an abscess has burst, or been opened, it continues in a progressive state of amendment for some time, and then becomes stationary, continuing to discharge matter without healing. This either takes place from the whole surface, or from a particular part of it, forming a sinus, the treatment of which will afterwards be mentioned, being the same with those which succeed abscesses which are originally unhealthy.