The lesson learned at Berry Head was not forgotten during the five subsequent years passed in British North America. The men were as healthy, the winds were sharper and colder, the vicissitudes of all kinds greater. Rum was cheaper, newer, and stronger than the gin of Torbay. The local inflammations were often as severe, whether of the pleura or of the lungs, and by no means less so of the bowels. A grenadier, some six feet three inches high, broad, and well framed in proportion, had drank a gallon of rum during the afternoon, and very narrowly escaped, even with the loss of nearly as much of his blood, abstracted in a few hours. His first bleeding was into the washhand-basin, until he fainted, lying on his back, and the bleedings were repeated as soon as he began to feel pain, and whenever he felt a return of the pain he used to put his arm out of bed to have the vein reopened, for Jack Martin was a very gallant fellow. This is given as an extreme case, to be borne in mind under circumstances somewhat similar, particularly after injuries. In common cases of well-marked pleuritis from injury in strong and healthy persons, it is now not unusual to abstract blood by those who rely on its efficiency, until the pain and difficulty of breathing are relieved, or fainting is about to take place. The patient should be raised in bed, the opening in the vein should be large, the flow of blood free. The quantity will vary from sixteen ounces to three times that amount in different people; but the important point is to repeat it as soon as the pain or difficulty in breathing returns. It rarely happens that one bleeding, to whatever extent it may be carried, will suffice to remove the symptoms; and recurrence should be had to this remedy as often as the pain and oppression require, and THE FORCE OF THE HEART will bear it, especially during the first two or three days. It will often be necessary to have recourse to it in smaller quantities for the next four or six days, and again in less quantity on any return of the inflammatory symptoms. Where the patient is likely to faint, he should be bled in the recumbent position; and as it is advisable to take away a sufficient quantity of blood, great care should be taken, by arresting its flow for a time, by giving stimulants, by admitting fresh air, and by sprinkling with cold water, to prevent syncope, which is sometimes dangerous in elderly persons, who may be subject to and who are not readily recovered from it. In the second stage of the complaint, profuse and repeated bleedings do not answer as well; they do not remove the evil which has occurred, although they may prevent its increase. Blood should then be drawn in such quantity only as will relieve the action of the heart, restless under its efforts to propel the blood through a hepatized lung. The quickness of pulse, the cough, the difficulty of breathing, must now be aided and relieved by other means; for although the pulse is not a certain indication, on which dependence can be placed in the early stage of this complaint, the breathing generally is; and as long as the respiration is oppressed, blood should be carefully abstracted, until it becomes manifest that the effect has been to quicken the pulse, while it materially diminishes its power, when it is forbidden.
307. A cupped and buffy state of the blood, together with a firm coagulum, is a satisfactory proof of the propriety of bleeding in the first stage of the disease; but after the effect of mercury on the system has been produced, it cannot be depended upon with the same degree of certainty. When the propriety of further venesection is doubtful, the greatest advantage may be obtained from the use of leeches and from cupping, particularly in cases of injury to the chest. Leeches may be applied by tens and twenties at a time; and when they have ceased to bleed into a warm bread and water or evaporating poultice, they may be replaced by as many more, until the pain and the oppression are removed. Cupping is always to be had recourse to when leeches cannot be obtained, and, when well done, it is frequently to be preferred; cupping to sixteen ounces will usually be found equivalent to forty or more leeches. Both these means often relieve to a greater extent, with less general depression, than a smaller quantity of blood taken from the arm, and are, therefore, at such times more advisable. When blood cannot be obtained from the veins, the arteries must furnish it; and both temporal arteries have been opened with the best effect in injuries of the chest, when blood could not be obtained from the arm, or from the external jugular vein.
308. The effects of bleeding were of old found to be different under different circumstances and in different climates. Asclepiades remarks that while phlebotomy was fatal at Rome and at Athens, it was beneficial in the Hellespont. Nevertheless, at a much later period, Baglivi says: “In Romano, phlebotomia est princeps remedium in plenritide.”
In the Crimea blood-letting has not been so favorably viewed, nor found so serviceable nor so necessary; although the abstraction of smaller quantities than those indicated above, and less frequently repeated, has been found eminently beneficial, the difference being dependent on climate and the impaired vigor of the sufferers.
The remedy first to be administered, and most to be depended upon in the first stage, is tartar emetic, which usually gives rise to vomiting, purging, and possibly to sweating; it should not be omitted because such effects are produced in the first instance. After a few, perhaps three or four doses, the vomiting usually ceases, the stomach tolerates its introduction, and its gradual increase from six to nine, twelve, twenty, or more grains in the twenty-four hours, is often borne not only with impunity, but with great advantage. Vomiting and purging are not desirable, as the effects of tartar emetic are more rapid and beneficial when they give rise to no particular evacuation beyond that of general perspiration. The most valuable remark of Laennec on its use is, “that by bleeding we almost always obtain a diminution of the fever, of the oppression, and of the bloody expectoration, so as to lead the patients and the attendants to believe that recovery is about to take place; after a few hours, however, the unfavorable symptoms return with fresh vigor; and the same scene is renewed often five or six times after as many venesections. On the other hand, I can state that I have never witnessed these renewed attacks under the use of tartar emetic.” He further says that the same favorable results do not occur from its use in pleurisy or in inflammation of serous membranes, as in pneumonia.
309. Mercury is a remedy of the greatest importance in serous inflammations, such as pleuritis, although of less value than tartar emetic in the first stage of pneumonia, than which it would appear to be more efficient in the later period of the stages of hepatization and infiltration, though some physicians place entire confidence on its efficacy in all. It is of most value when combined with opium. Some suppose that the opium merely prevents the irregular action of the mercury; others, in some papers printed in the journals for 1801, state that opium has a distinct curative effect, being capable, when given in large doses, of subduing inflammation, and more particularly of allaying pain, relieving the cough and irritation, and of procuring sleep; in which opinion I fully concur. Opium is highly advantageous in irritable and nervous persons, and will frequently relieve the nervous pain, the pleurodynia which remains after pleuritis, when nothing else succeeds. Calomel in large doses is usually preferred to all other forms, but a difference of opinion has occurred as to what is a large dose; whether two, three, four, six, ten, or twelve grains are large doses, and whether they shall be given every one, two, three, four, or six hours. It has been attempted to solve this question by supposing that in highly inflammatory cases in healthy persons, from three to six, and even to twelve grains, may be given twice or three times a day, with better effect than smaller ones more frequently repeated; but this has not been made manifest.
In cases less inflammatory or complicated with gastric derangement, the disease assuming more of a general than of a local character, the excretions being vitiated, the skin dry and hot, and the tongue loaded, from gr. iss to gr. iij of calomel, combined with three grains of Dover’s powder, may be advantageously given every second or third hour, the great object being to affect the gums as quickly as possible. This is not effected in some cases by any of the quantities given until after a considerable lapse of time, while in others it is accomplished by less than half a dozen grains of the remedy. It has not been ascertained that twenty-four or forty grains given in two or four doses in twenty-four hours will affect the mouth more rapidly than three grains every two hours for the same time, neither is it less liable to cause irritation; while the third or half a grain of opium given every two hours seems to keep up the effect of that remedy with great advantage. It does not materially signify which method is adopted in strong and healthy persons, although the smaller doses are most satisfactory to all parties when the patient is weak and irritable, while the large and less frequent doses often excite great apprehension. It is argued that calomel in large doses never causes the dysentery nor the severe ptyalism produced by smaller doses; that it acts more quickly, and that after giving twenty grains, and repeating it in six hours, any other medicines may be given without interfering with it, although the strictest attention must be paid to diet, generally confining it to very small sups of warm whey. Very serious derangements do, however, follow the exhibition of the large as well as of the small doses, inasmuch as it is impossible to know beforehand what quantity will cause a severe salivation or diarrhœa, which it may be difficult to arrest.
310. It may be concluded that, of the two heroic internal remedies, tartar emetic and calomel, recommended for the cure of inflammation of the chest, tartar emetic is the more appropriate for inflammation of the lungs or pneumonia, provided it be not accompanied by symptoms of gastric inflammation; in which case its use should be superseded by leeches to the epigastrium, and saline aperients, lest the irritation, vomiting, and purging should increase the evil. But care must be taken that one inflammation shall not be allowed to increase, while attention is principally paid to the other, and symptoms of irritation, the gastro-enterite of the French physicians, are not to be mistaken for gastritis. Mercury, in the form of calomel, is more to be depended upon in inflammation of the pleura, over which, as well as over inflammation of serous membranes in other parts of the body, it exercises a remarkable influence.
311. Blisters are never useful during the continuance of acute inflammation of the chest, although their use is indicated when the patient is much exhausted, the pulse weak, and the breathing continues difficult; or in cases in which the disease proceeds slowly, or is becoming chronic, when they often do much good. The same may be said of dry cupping, mustard poultices, and other cutaneous rubefacients, such as the ol. terebinth. used hot, which often do much good in the commencement and termination of slight attacks, or of their supervention on chronic disease, or after injuries.
In the acute stages simple drinks only should be allowed. As soon as the inflammatory action has subsided, the lightest farinaceous nourishment, gradually augmented by the addition of broths, jellies, eggs, fish, and lastly of animal food, should be substituted. The temperature of the room ought to be moderate and equal.