DISSERTATION II. CONTINUED.

ON

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 out1. 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.

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 it2; 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.

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 moment3. 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.

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 progressive4. 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.

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 general5. 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.

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 lungs6. 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.

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 produced7.

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 ascertained8.

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 hurtful9, 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 action10, 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.

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 itself11, 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.

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 recovery12. 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.

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 does13: 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.

Alcohol is likewise considered by some as a sedative, and introduced as a remedy, in the enumeration of those which are applicable in inflammation14; but, whatever its use may be in the inflammatio debilis, it must be allowed to be evidently hurtful in the inflammatio valida.

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 peculiar15 action of the individual artery being affected16, and the contracting state of the orifice, spreading along the branch and trunk by degrees17, 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.

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 weakness18, 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 internally19.

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 excited20. 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 time21.

There are two forms in which we employ heat and moisture, namely, fomentations and poultices. Fomentations22 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.

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 quickly23. 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 action24; 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 hard25, 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 association26, 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.

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 extent27. 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.

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 burst28, 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 cavity29, 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 afterwards30, 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.

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 tedious31. 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.

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 poultice32, 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 abscess33, 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.

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 case34, 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 particles35. 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.

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 caries36 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.

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 pencil37. 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 osseous38.

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 exists39, 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 sinus40. 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.

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 recommended41; 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.

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 exercise42, 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 commences43. 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 action44. 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.

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 one45; 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.

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 part46; 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.

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.

GENUS I.

Of the Healthy Ulcer.

From these remarks, as well as from those which were formerly made, it will appear, that a healthy ulcer has a natural tendency to heal, and that we ought only to be careful not to interrupt the natural progress, nor allow the action to flag.

In this genus of ulcers, the bottom of the sore seems to be paved with a number of small fleshy points, with minute interstices betwixt them, or surrounding their bases. These are of a red colour, with a slight shade of the purple, and are wet with a yellowish fluid, which is called pus; but which must of necessity differ from the fluid yielded by suppuration. This separates freely from the surface, when it is wiped or touched with a sponge, and then the granulations may be distinctly observed47. The margins are smooth, thin, and a very little rounded, that is to say, are almost imperceptibly raised above the granulations, a circumstance which is essential to this ulcer, because, were they both on the same level, it would show, that the cicatrizing process did not go on properly; for, whenever the granulations rise to the level of the surface, they ought instantly to form skin. This cicatrix, which extends gradually from the circumference to the centre, is of a pale red colour; but the integuments immediately beyond it are white, and of the natural appearance. Sometimes, from a slight deviation or imperfection, one spot of the disk rises to the level sooner than the rest; but, in this case, it immediately skins, and the cicatrix extends from this in the same way as from the circumference, until they both meet. The sore is free from pain, the only sensation being a slight degree of smarting, or itchiness.

The treatment of this ulcer is very simple; for, in most cases, it is only essentially necessary that we prevent the operation of hurtful causes. We defend the part, by covering it with a soft pledget of lint, and keep it warm. When the cicatrization has commenced, it may be assisted by using an ointment containing any harmless powder, in such a proportion as to form a paste or scab upon the part48, by which we afford an artificial covering, which remains in close contact with the granulations; and, by thus bringing them nearly into the same circumstances as when skin is formed, the cicatrizing action is accelerated. The same effect is sometimes produced, by allowing the pus to form a scab over superficial sores, by exposing them to the air, without any covering.

Dry lint is a very useful application; but, as it is apt to stick to the granulations, and tear them, when tender, it ought always to be well moistened before removal, which should be attempted slowly.

Mild ointments, such as the simple cerate, are frequently employed; but they must be free from all rancidity, otherwise they fret the skin, or injure the sore. In general, they are less useful than dry lint. When we do employ them, they ought to be applied only to the granulations and cicatrix, and not to the sound skin. More frequently we use these ointments spread on a pledget of linen, to keep the dry lint on the sore.

Poultices are also recommended in these cases; but they possess no peculiar advantage, and are apt to make the part feeble, and more likely to break out again.

Moderate pressure, by keeping up the action, is generally of service; but it is still more necessary when the action begins to flag, or becomes stationary. In this case, a compress ought to be placed over the sore, and the whole member rolled firmly round with a cotton bandage or, what will be still more useful, the part should be encircled with strips, spread with adhesive plaster, in the way which will afterwards be mentioned. Pressure acts by taking away the condition of vacuity; it forms an artificial covering and interstices for the superficial granulations, by which the natural process of forming granulation and skin is greatly assisted. The parts are, in this way, not only more quickly formed, but also in greater perfection; and their powers of action are greater. The cure is therefore more permanent, and the part is not so apt to die, or ulcerate again, as when healed with simple dressings.