SIMPLE INFLAMMATION,

_And its Consequences_.

_Of the Cure of Inflammation._

In attempting the cure of inflammation, or its consequences, we must

naturally be directed to the means of removal, by the nature of the

action itself, and the object which we have in view. The treatment

of the inflammatory action may be considered in two points of view;

first, as this action consists in peculiar changes of the natural

action, which changes we wish to remove; and, secondly, as this action

naturally tends to disappear, and produce other actions, which require

a peculiar treatment. The observations, therefore, which are to be

made upon the method of cure, may be arranged under the heads of the

different terminations of inflammation.

_Of the Treatment necessary to procure Resolution._

In the treatment of most wounds, our chief intention is to prevent

the accession of inflammation, and procure adhesion, which is, in one

respect, analogous to resolution. When inflammation has taken place,

either in wounds, or in other cases, our great object is, to remove or

lessen it as quickly as possible, which we effect, first, by removing

the exciting causes of inflammation, or such causes as tend to increase

the action; and, secondly, by applying such remedies as tend directly

to abate the inflammatory action.

Upon the propriety of removing the exciting causes, and the manner of

doing so, very little requires to be said. If any acrid, or stimulating

substance, has been applied to the skin, or any extraneous body been

forced into it, these must be removed before the inflammation can

be resolved; because, if they be allowed to remain, they will keep

up the action so long, and to such a degree, that suppuration will

be produced, or gangrene, if the part be very sensible, (as, for

instance, the cutis) or if the exciting cause be very irritating.

Acrid substances are to be removed by ablution with water, which is

in general much better than the solutions which are proposed upon

the principle of chemically combining with the acrid; because these

generally are likewise acrid, or stimulating, and increase still more

the inflammation which has taken place, before they can combine with

the substance which was formerly applied, and become neutralised. This

may be illustrated by the operations of acids and alkalis. If heat

have been applied, so as to induce inflammation, we must remove the

superabundant quantity of heat, but must not apply cold; because we

then do mischief, as will be afterwards mentioned.

When a substance is forced into the skin, so as to stimulate

mechanically, we must endeavour to lay hold of it, and pull it out;

but if it have penetrated so deep as to make this impracticable, we

must then enlarge the wound, and remove it; because we thus may enable

the wound to heal by the first intention. If, however, the injury done

be great, if the part be much bruised, or the extraneous substances

be numerous, we may be less anxious about the extraction of such as

require much trouble; because the irritation which is thus given will

tend to increase the degree of inflammation, and, very probably, its

extent, at the same time, that, from the original injury, there is

little prospect of adhesion being procured, or suppuration prevented.

We are then chiefly to search after, and extract foreign bodies, when

we apprehend that their removal may permit the inflammation to be

resolved, and adhesion to take place, and when we expect that their

presence will excite a greater action than our endeavours to extract

them will do. This is a rule which ought to be carefully remembered by

every surgeon, and especially by those whose situation makes them be

daily called to take the management of gun-shot wounds. They are not

brought to their patient to show how much they can do in the way of

cutting and probing; it is their duty to administer relief, and act so

as to prevent and abate the inflammatory action, which they will often

do most effectually by letting their patient alone, and throwing aside

their ball-screws and forceps.

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[1]. 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.

[1] 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[2]; 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.

[2] 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[3]. 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.

[3] 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[4]. 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.

[4] 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[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.

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.

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[28], 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[29], 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[30], 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.

[28] Such as the thorax, trachea, &c. Instances have happened of

suffocation being thus produced.

[29] 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.

[30] 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[31]. 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.

[31] 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.

After an abscess bursts, the proper application is a warm poultice[32],

which should be continued in general as long as there is any stool,

or hard margin; that is to say, until the increased quantity of

diseased organic particles, which were formed during the inflammation,

be absorbed, and the vessels at that part have either assumed the

suppurative or natural action. After this, the orifice ought to be

covered with a slip of lint, and moderate pressure applied over the

surface of the abscess[33], by which the sides are kept in constant

contact, and reunion is accelerated. Good diet is also necessary,

for we thus increase the powers of recovery, or keep up a proper

action, and renew the vital principle, the quantity of which has been

lessened during the inflammation, both by the continuance of a state

of overaction, and by the remedies which are employed to diminish the

action; for a state of real and permanent weakness is thus induced.

[32] This poultice does not require to be so hot, nor changed so

frequently, as before the full formation of matter.

[33] If this produces pain, we may in general conclude that it has been

used too soon.

It sometimes happens, that suppuration takes place very slowly, and

the action seems to be performed with little vigour. In this case,

if the abscess be allowed to burst of itself, we both lose time, and

are often, in the end, disappointed in a cure, the healing process

not taking place. It is therefore useful, in these cases, to have

recourse to other agents besides heat. If the pain be trifling, and

the suppuration be what may be called chronic, or approaching to it,

we will perhaps succeed, by applying gentle pressure on the abscess,

by means of a thin roller, and laying a warm poultice over this. But,

when this fails to increase the action, we ought to pass a seton, by

which we evacuate the matter, and keep up the subsequent action to a

degree sufficient for producing recovery. In doing this, however, it is

necessary to attend to the state of the tumor; because, if, in every

instance, we pass it from the highest to the lowest part, we shall

sometimes make the part give way in a third place. If, for instance,

the abscess be much thinner at the apex than elsewhere, or, if the

action have made considerable progress toward the surface, then the

stimulus of the action increases the performance of the natural process

which was going on, and the action continues to extend itself until

the part gives way. In these cases, then, we ought to pass the seton

from the thin part to the lowest part; and this, in general, will, from

the sympathy of association, be sufficient to excite the action of the

whole internal surface.

When we resolve to use the seton, the following is the easiest method

of introducing it: Make a puncture with a lancet either into the upper,

or the thinnest, and most prominent part of the tumor, according to

circumstances; and, into this puncture, introduce, using the lancet as

a directer, a probe, having a piece of tape passed through its eye.

The lancet is then to be withdrawn, and the probe pushed down to the

under part of the abscess, where its point will be felt under the skin.

A small incision is here to be made upon the knob of the probe, which

is next to be passed through, and the tape drawn after it. The matter

is then to be slowly pressed out; the tape is to be folded; and the

abscess bound up with a compress and roller, so as to make moderate

pressure upon it. Next day, the dressings are to be removed, and a

clean piece of the tape drawn through, after which, pressure is again

to be applied.

The size of the tape, the time which the seton ought to be employed,

and the degree of pressure to be used, must be regulated by

backwardness of the action, and the imperfection of the healing

process.

If, either from improper management, or the morbid condition of the

action, the abscess, after it bursts spontaneously, or is opened by

art, continue to suppurate, without undergoing the ulcerative action

preparatory to healing, then we find, that either the sides remain

quite separate, producing a cavity, extended more or less, or one

particular portion remains open, forming a sinus. Both of these cases

require a treatment, which, in its principle, is the same, namely, the

indication of the ulcerative action.

In the first case[34], we shall frequently succeed by means of the

seton, especially if we use pressure alongst with it; for, by keeping

the internal surface in close contact, we tend to check the purulent,

or suppurative action, and produce organic particles[35]. We may also

succeed, by using stimulating injections, of such a strength as to

produce a moderate degree of smarting. Of this kind are, wine and

water, solutions of white vitriol, corrosive sublimate, &c. These ought

to be used frequently in the course of the day, and pressure employed

during the intervals. Incision, or laying the part open, is, being the

most severe, the last remedy which is to be had recourse to. Small

chronic abscesses may be laid open during their whole diameter; but

larger ones require only to be cut up for a certain length.

[34] This is exactly similar to an encysted tumor which has been

opened, and requires the same treatment. The internal surface becomes

thick and somewhat hard, like that of a cyst. It differs from an

encysted tumor only in its cause and origin.

[35] If pressure be employed early, to a considerable degree, the

irritation of the means employed produces pain, and a morbid increase

of action, unless we keep down the action by cold, as will be explained

when considering the treatment of ulcers.

The second case, has generally been considered as a species of ulcer,

and has been named the sinus ulcer; but, although the orifice may

sometimes possess the diseased ulcerative action, yet the sinus itself

still continues in the suppurative state, and, therefore, cannot heal.

These sinuses depend, in different instances, upon very different

causes, and, therefore, require a variation in the treatment. The most

simple species of sinus may be called mechanical, and is produced

by matter flowing from a neighbouring cavity, and which cannot be

freely discharged: Thus, for instance, if a deep abscess open at the

highest part, or at a point above the level of its bottom, the matter

constantly oozes out, and keeps the canal open. This is most apt to

occur, when abscesses are formed deep amongst muscular parts; in which

case, although the matter point at the centre, yet an accumulation

must take place below, and the matter must continue to be discharged by

the aperture, when it becomes so abundant as to be raised to the level

of the opening; or, being once raised, it continues to flow out. The

cure of this may at first be attempted mechanically, by tight bandages,

which press out the matter, and keep the sides in contact; but, if the

disease have been of long duration, then, whatever may have been its

nature at first, we find, that the suppurative action extends along the

mechanical sinus, which then becomes affected with a chronic action;

in which case, it becomes similar to the second species of sinus. We

must, in this species, make an opening at the most dependent part, and

employ the means which will be now mentioned in considering the second

species, or that produced in consequence of the suppurative action

becoming chronic or habitual, independent of any mechanical cause.

This may take place, although the aperture have been originally in a

proper place, and the matter, instead of being retained and keeping up

the disease, shall have been regularly discharged. The case in which

this is most likely to happen, is that in which the abscess has been

very tedious in its progress, and the action has been, from the first,

slow. The distinction betwixt this species, and those which remain

to be mentioned, is founded upon the absence of the symptoms which

they possess, and by our examination with the probe, which points

out the cause and extent, and informs us whether we be near a bone.

The orifice is flabby, and has the appearance of the indolent ulcer.

The cure of these sinuses is to be attempted, by pressing out the

matter by means of proper bandages, or by making a dependent opening,

which is generally necessary, at the same time that we raise the

action of the part to a proper degree, and render the suppurative

action acute and vigorous; in which case, it naturally terminates in

the ulcerative, and thus the part has its structure restored. This

is most easily effected, by passing a seton, and applying a proper

degree of pressure, diminishing the size of the seton gradually, and

in proportion to the vigour of the action and the approximation toward

health. When, from the situation of the sinus, we cannot pass a seton

(which rarely happens in this species of sinus), injections of wine

may be used frequently, and pressure applied during the intervals.

When these means fail, which is seldom the case, the part should, if

its structure permit, be laid open. If this sinus have remained long

open, its surface, like that of the chronic abscess, becomes changed,

and a coat is formed, like the cyst of a tumour. When this is thick

and hard, the sinus has been called a fistula, and it has been deemed

necessary to dissect out the tube; but it is in general sufficient to

use the remedies which increase the vigour of the action, and make it

run its natural progress; such as the seton, or a free incision, if the

parts be superficial, or no considerable vessel or nerve runs the risk

of being wounded.

The third species of sinus is that in which the suppurative action is

kept up by the operation of some adventitious cause; such as a caries

bone, diseased cartilage, or the lodgement of a foreign body; as, for

instance, a ball, a splinter of wood, bit of cloth, &c. This species

is distinguished by our feeling the extraneous body, or diseased bone,

with the probe, and by the fungous protuberance, or papilla, which

shoots out from the orifice. In addition to the method of curing other

sinuses, we must here endeavour to remove the adventitious cause, which

is generally very difficult to be done. If the foreign body be deep,

or if the diseased bone lie deep, and the sinus be narrow, we can do

little in this way; sometimes, indeed, by enlarging the external part,

we can come at the foreign body with a pair of small forceps, and may

extract it, or may accelerate the exfoliation of the diseased bone;

but we can have no certainty of success. If, however, the sinus be

superficial, which sometimes happens in caries of the tibia, &c. it

ought, in every instance, to be fully laid open, and the bone exposed,

and treated in the way immediately to be mentioned. When this cannot

be done, we may sometimes, by conveying the proper remedies through

a tube down to the bone, procure exfoliation; or may, by setons,

injections, and pressure, procure a temporary cure; but, as long as

the adventitious cause remains, we cannot expect a permanent recovery.

It is observed, that sinuses, when they can be healed in these

circumstances, break out again upon very trifling exertions, and very

frequently are renewed, after a short interval, in spite of all our

precautions; such as rest, warmth, &c.

A caries[36] of the bone is at all times a disease which is difficult

to manage, both on account of the mechanical obstacles which we have

to overcome, and the slowness with which the affected parts perform

their actions either of disease or recovery. The divisions of this

disease have generally been taken from the appearance of the caries,

and its extent. We have the dry caries, the worm-eaten caries, the

spongy, or carnous caries, &c. and we have the deep and superficial.

But, as the cure of these is to be conducted on the same principles in

all of them, and as they are most probably different degrees of the

same complaint, it will be more useful to divide them into those which

affect bones lying deeply, and those which affect the more superficial

bones; because these different cases are attended with very different

circumstances and symptoms. The first is preceded by an abscess, which

forms generally with much pain, runs its course slowly, and does not

burst for a considerable time. When it does open, its sides do not

ulcerate, at least universally, but a sinus remains, the mouth, or

exposed part of which only, assumes the ulcerative action. The second

is more rarely preceded by any abscess, but is either coeval with the

ulcer of soft parts, (both being produced by mechanical violence) or

it succeeds the ulcer, and is caused by it. This ulcer belongs to the

third genus, and will be afterwards described.

[36] When a bone becomes carious, the periosteum is completely

detached, and, therefore, it is felt to be rough by the probe. Its

colour becomes first of a dull white, or dirty yellow, which it either

preserves, or changes for the intermediate hues betwixt these and

black. It is generally more porous than formerly, and lighter; but

these qualities vary, from very slight degrees, to the appearance of a

light coralline.

In treating of the cure of caries, the first thing is, to determine

by what means the disease of the bone may be removed; and, secondly,

what modification our treatment must undergo, in consequence of

the caries belonging to the first or second species. From the very

earliest periods, we find the application of stimulating and corrosive

remedies recommended in this disease. The actual cautery, euphorbium,

mineral acids, scalding oil, the essential oils, and warm balsams,

have been universally employed, and frequently alternated with rasping

and perforating the bone. This proceeded from observing, that, on

the one hand, mild applications had no effect, and, on the other,

that the natural slowness of exfoliation was overcome by the use of

these more powerful remedies. A caries of a bone is correspondent to

a mortification of a soft part; and, therefore, it is impossible to

restore the diseased part to health, or life. Our chief object, then,

must be to prevent the disease from spreading, and to procure a speedy

separation of the dead portion. The first is much less under our power

than the second; for, it is most probable, that, in the majority of

instances, at least of those of a simple nature, the disease, from the

first, extends a certain length, affecting a portion of the bone, and

that it afterwards makes very little progress. There is, however, a

specific disease which affects the bone in common with the soft parts.

The bone becomes rough, and suppurates; and the soft parts have a

fiery appearance: This has been called the phagedenic caries. Cancer,

scrophula, lues, and other specific actions, also spread after they

are once induced. The second object is to be effected by such means

as operate upon the vitality and action of the part, and those which

act mechanically. Those which tend mechanically to remove the dead

portion, are perforations down to the sound part, which we know has

happened, by the bleeding which ensues; or, we may saw down this length

with a trephine. We thus, by cutting off the communication of part

of the diseased surface with the adjacent parts, kill it completely,

sooner than could otherwise happen, and likewise stimulate the parts

below to assume the ulcerative action, and throw it off. We may also

sometimes be able to turn out these portions with a levator. Those

which act more exclusively, by affecting the action of the part, are

stimulating applications; such as heat, acids, &c. The actual cautery

is so terrifying to the patient, that it is now laid aside; and it

is likewise liable to this objection, that it may, by its operation

on the neighbouring parts of the bone, produce disease in them. The

potential cautery is more useful, and may frequently be employed with

advantage, either in a solid form, as to callus, &c. or dissolved

in water, and applied with a pencil[37]. M. Sue, in his notes to

Ravaton’s Practique, &c. recommends l’eau mercurielle, or solution of

mercury, in nitrous acid. By these means, the sound part below assumes

the ulcerative action, its connection with the diseased portion is then

destroyed, and reparation takes place. The ulcer of the bone is red,

and its surface covered with innumerable granulations, which rise up to

the level of the surrounding parts, after which a cicatrice is formed.

These granulations in the bone are absorbed, and others more perfect

are deposited in their place, until at last they become completely

osseous[38].

[37] If we use the solution, we must, if the bone be very porous, or

spongy, apply only a little at once, otherwise it may sink down, and

injure a part which we do not wish to act on.

[38] There is a curious case of caries, which is frequently met with:

The diseased part, instead of being cast off, is surrounded by a

covering of new bone, (except at one portion, where a sinus and ulcer

is formed in the soft parts) and may be felt rattling within it. In

this case, there is necessarily a permanent enlargement of the part,

from the additional bony matter; and this, together with the sinous

openings, and the internal caries, being felt with the probe, form the

character of the disease, which has been called necrosis, a term which

formerly implied merely mortification. The cure of this complaint is to

be accomplished by extracting the diseased part, when it becomes loose,

if the opening in the case be sufficiently large; if not, it is to be

enlarged with the trephine, &c. See the works of Ruysch, Default, &c.;

and, more lately, the publication of Mr. Russel.

The next point which merits our attention, is the situation of the

bone, and the circumstances which attend the caries. When superficial,

a fungous ulcer is produced, and the modification which this situation

requires in the application of the general plan will come afterwards

to be attended to; the modification in the treatment which is required

in sinuses has been mentioned above. It may here only be remarked,

that, where the sinuses are superficial, they may be laid open, which

will induce the ulcerative action in their course, and allow us to

apply the proper remedies to the bone; but where they run deep, we

must either allow the disease to run its natural progress, and treat

the constitution according to the effects produced, or, by means of a

canula, convey a piece of caustic to the diseased part, in the same way

as we treat obstinate strictures of the urethra, &c. When, with the

probe, we feel the bone loose, we may assist its exit with the forceps,

or by enlarging part of the sinus, according to circumstances.

When these sinuses communicate with joints, and depend upon diseased

cartilages, tendons, or articulating surfaces of the bones, we can

do very little in the way of curing them by injections or incisions;

because we cannot thus remove the disease of the joint, but may

increase it. Issues placed over the joint, with rest, cleanliness, and

good diet, country air, &c. are the remedies chiefly to be employed

in these cases; or, if hectic be induced, and these remedies fail, we

must remove the diseased part, if this, on account of its situation, be

practicable. When, however, these sinuses are superficial, and depend

upon tendons not immediately connected with the articulation, it may

be useful to lay them open, and treat the disease of the tendons with

caustic, like a caries of a bone, or with escharotics, and stimulating

applications.

The fourth species of sinuses, are those where a specific action

exists[39], and prevents the healthy ulcerative action from forming. Of

this kind is the scrophulous sinus, which is generally accompanied with

a caries bone, or diseased cartilage, and, therefore, is a complicated

sinus[40]. This is distinguished, where the bone is diseased, by a

shining or polished red skin, like a cicatrix, surrounding the fungus

papilla at the orifice of the sinus, or the scrophulous-looking sore

which exists there. When no caries bone exists, we have no papilla,

but only the diseased ulcer at the orifice. In both cases, there are

generally the marks of a scrophulous habit. In the first case, we are

to treat the sinus as if it were of the third species. In the second

case, we are to treat it as if of the second, conjoining the proper

remedies internally, as will be mentioned in considering the cure of

scrophulous action. These sinuses, although healed, have a tendency to

break out again, especially in the spring or summer.

[39] These sinuses cannot be considered in this dissertation.

[40] This may sometimes be produced by the formation of an abscess,

without any evident cause; but at other times it is produced by wounds,

&c. in scrophulous habits.

The effects of the suppurative action upon the constitution, may be

divided into those which are dependent upon the formation of the

action, such as coldness, listlessness, &c. which are common to all

new actions; and those which are peculiar to the action when fully

formed. The first set requires no particular treatment, with an

immediate reference to their removal; but their presence indicates the

necessity of changing our method of cure, if we have not already done

so. In conjunction with proper local applications, we must give light

nourishing diet, with or without wine, according to the extent of the

action and the weakness of the patient. Rest, and general warmth, are

also necessary; but the heat ought not to be carried so far as to

produce any considerable sensation, or sweating. Diaphoretics have been

recommended[41]; but there does not appear to be any necessity for

their exhibition; because the cold, and other symptoms which we intend

to relieve, depend upon the state of the local action, and are only

to be removed by fully forming this action. Heat will not cure this

coldness, or shivering, when the action which causes it is extensive;

but, on the contrary, will frequently increase it, by accelerating the

formative process. The immediate effects, then, or the primary symptoms

of suppuration, require no particular treatment, with a view to their

own removal, but are to be attended to as marks which point out the

necessity of a change of treatment, with a view to keep up the action

which induces them, and to prevent it from producing bad consequences

afterwards to the constitution. Sometimes, indeed, in delicate people,

suppuration at this period produces hysterical symptoms, such as

languor, flatulence, or sometimes starting, tremors, and hysteric

paroxysms, more or less distinct. The slighter affections of this kind

may be frequently removed by a little warm wine and water; the more

severe, by anodynes, conjoined with aromatic waters.

[41] Mr. Hunter supposes that these are useful, “because they endeavour

to keep up an universal harmony, by putting the skin in good humour,

which quiets every sympathising part, and by counteracting the effects

of irritability.” P. 381.

The second set of symptoms, or effects, are those which have been

already described under the name of hectic, the production of which

has formerly been explained. This action, when slight, has been called

weakness, and has been considered as dependent upon the quantity of

the discharge; but, for the reasons formerly mentioned, this cannot be

admitted. The cure of this state is to be attempted, by lessening the

local action, at the same time that we give soups, and other articles

of nourishing diet, with a moderate proportion of wine, if this do

not quicken the pulse, and produce heat of the skin. Anodynes in the

evening, by procuring rest, will also be useful; but none of these

remedies will produce their proper effect, unless the patient respire

a pure air. Bark is considered as useful in these cases; but, unless

good diet be conjoined, it is not of much benefit. If, however, we give

the means of increasing the quantity of vital power, bark, by inducing

an action more nearly resembling the natural one, will be serviceable;

but, for this purpose, it must be exhibited in full doses. It is from

giving this medicine too sparingly, and in cases where other causes,

tending to counteract its effects, such as poor diet, bad air, &c.

are allowed to remain and operate, that bark has been brought into

disrepute.

When the general action is very considerable, then the exquisite

hectic is induced, and the situation of the patient becomes alarming.

When the local action is simply the suppurative or ulcerative action,

we may consider that the general disease is also simple, and are to

attempt the cure by the remedies which have been just now mentioned.

In conjunction with such local applications as tend to check the

local action, we must have recourse to all those means which tend

to strengthen or renew the natural action of the system in general;

for which purpose, we must attend, in the first place, to all the

particular functions, or individual parts; and, in the second, to

the whole in the aggregate. Under the second head are included bark

and wine, with moderate exercise[42], and proper diet; in the choice

of which, we must be directed by the nourishment which is yielded,

and by the capability of digesting the articles which we employ. In

general, milk, soups, and jellies, answer best. Under the first head

are included such remedies as tend to promote digestion, such as steel,

bitters, mineral acids, &c. although in general the bark will supersede

their use. The state of the bowels must also be attended to, avoiding

costiveness on the one hand, and diarrhœa on the other. The secretion

of the skin must also be regulated, stopping the colliquative sweating,

if possible, by getting up for some time when it commences[43].

Lessening the quantity of bed-clothes, for a few minutes, will also

sometimes interrupt it; but when it has continued long, it can only be

checked by removing the diseased action[44]. A full dose of the bark

given before the accession of the sweat, may sometimes, by influencing

the morbid action, prevent the discharge. The respiration must in

particular be attended to; for, by breathing country and pure air,

the action of respiration is more fully performed, and, consequently,

the source of vitality is increased, and the effects of our other

remedies are increased. The importance of a change of air can only

be known by those who have observed how fast patients have recovered

from operations when removed to the country, and clean lodgings, with

well-aired beds, although before this they were daily sinking. Indeed

no capital operation, which is likely to induce the suppurative action,

ought to be performed, where cleanliness, and a free circulation of

air, free from fœtor, cannot be procured.

[42] Exercise may be used either on foot, or on horseback, or in a

carriage; and its degree must be regulated by the strength. There are

few patients who cannot bear moderate exercise (were it no more than

walking half a minute in a garden), and who will not be the better of

this.

[43] Acids are supposed to check it; but they can only act by

increasing the strength in a secondary way.

[44] Sweating is perhaps to the general hectic action what the

suppuration is to the local one; and, therefore, can only be stopped by

influencing this action.

It is not yet discovered that any remedy has a specific power of

removing the hectic, or diseased formative action, more than the local

purulent one[45]; and, therefore, we are obliged solely to trust to

these already mentioned, which have a natural tendency to increase the

healthy action, or induce one nearly similar to it, and especially to a

proper local treatment, by which we remove the exciting cause.

[45] A diet solely animal has been proposed in that peculiar species

of hectic which accompanies diabetes; but whether it would be equally

useful in other species remains to be determined.

When these remedies fail, and the disease seems to continue, or

increase, in spite both of general and local remedies, then we must,

if it be practicable, remove the diseased part by an operation; and,

in doing so, we must remember, that delay beyond a certain period

is dangerous; because the general action becomes so rooted, and the

strength so reduced, that recovery cannot take place. Operating in

these circumstances, therefore, can only hasten death. The wound will

not unite nor heal, and the general action will continue unabated.

When the local action is specific, the general one is also different

from the simple hectic; and, therefore the remedies which are useful

in simple hectic will not be of equal advantage in these cases, unless

a specific remedy be conjoined, as, for instance, mercury prudently

exhibited in the venereal hectic, dependent upon a neglected local

complaint. The most frequent instance of specific hectic is the

scrophulous; for the cure of which we possess no remedy which acts

with certainty. Whenever, therefore, the local complaint cannot be

cured, and the hectic increases, we must, if possible, remove the

diseased part[46]; after which, the general action, notwithstanding

its specific nature, most commonly declines; but the constitution still

remains, as formerly, scrophulous, or even more so than before. That

this is the case, would appear from the following fact: If a person

slightly scrophulous, although originally sprung from a scrophulous

stock, or in whom the constitutional disease seems to be disappearing,

in consequence of intermarriages, &c. has, by means of a local injury

done to a joint, &c. the scrophulous action excited, and consequent

hectic, that person will, after cure, have the tendency to scrophula

stronger in him than formerly; and the disease will even frequently be

communicated to his children with its original violence.

[46] When this disease attacks the lungs, as it too frequently does,

then, until a specific remedy for scrophula be discovered, no cure can

be obtained. Simple ulceration, or suppuration of the lungs, however,

and consequent hectic, may be cured, though not in every instance.

_Of the Treatment of the Ulcerative Action._

Suppuration is a natural termination of inflammation; and the

ulcerative action is invariably induced by the suppurative, unless

this remain chronic. The ulcerative action is to be considered as in

part a restoration of the natural one; for we find, that it produces a

restoration of the structure, granulations being formed by the vessels

which formerly supplied the organic particles, whilst the interstitial

vessels still yield a morbid fluid, called pus; but this they cease

to do, whenever they again are placed in the natural situation; that

is to say, whenever they become covered with the granulations, or are

rendered interstitial. In proportion, then, as granulations are formed,

a certain number of vessels are rendered interstitial, so that the

discharge gradually diminishes, until at last it ceases; for, when

we come to the formation of a cuticle, we have very few interstitial

vessels left, the skin having naturally few. At this time, the one set

of vessels having completed their action, and the part being restored,

the other also resume their action, and a thin exhalent fluid is thrown

out by the new cuticle, which keeps it soft and moist, and which is the

natural insensible perspiration. The action of the two sets of vessels,

then, is dependent on each other; and, whenever one is diseased, the

other becomes also more or less so.