By removing, then, the exciting causes of inflammation, before the action be induced, we shall frequently prevent it altogether from being formed; but, even although we should be disappointed, we, by this removal, render the disease milder, less extensive, and much more easily overcome; for, as long as the exciting causes continue to operate, it is impossible to procure resolution; but the action will be kept up until some other termination, or consequence, be induced. But, although we thus prevent the action from being raised to so great a degree as it otherwise would be, yet we do not immediately overcome or destroy it; because the action, when once induced, has, like every other action, a tendency to continue for some time after its cause is withdrawn. This continuance may be longer or shorter, according to circumstances, and its termination may be more or less unfavourable. We are, therefore, under the necessity of employing such remedies as have a power of directly diminishing or removing this action. It has, however, been doubted, whether they ought, in every instance, to be employed; or, in other words, whether resolution ought uniformly to be desired. It has, for instance, been deemed unsafe to check those inflammations which depended upon a general or constitutional specific disease, or occurred during its existence. But this opinion, which was evidently founded upon the supposition of the operation of morbid humours, cannot be maintained, now that this is given up. Granting inflammation, in every one of these cases, to be dependent upon the general disease, and to exist as a symptom of it, no harm can accrue from resolving it[2]; because, if the inflammation have once taken place, the full effect of the general disease is produced, which, therefore, cannot be affected by the peculiarity of the termination of this inflammation, unless it be proved, that some humour be sent there to be concocted and thrown out. In many instances, inflammation occurs in a general disease, merely as an accidental circumstance; but, even in those cases where the local inflammation is most decidedly dependent on the general action, and is perhaps essential to it, we find, that no bad effects follow from resolving the inflammation; and, if this be the case with regard to specific inflammation, we may still more certainly extend the principle to the treatment of the simple inflammatory action, with which we have at present a more immediate connection. There are, however, some inflammatory affections which we sometimes cannot put back; such as those tumors which succeed the small-pox; but, when we do succeed, no bad consequence follows; and the failure of some of our attempts can be no argument against the general plan, more than our failure in many other instances.
Resolution is the quickest termination of inflammation, and, therefore, ought, perhaps in every instance, to be attempted, unless in cases where the injury is such that suppuration is unavoidable; as, for instance, extensive bruises, &c. It is our great object, even in those inflammations which we raise intentionally; as, for instance, in the operation for hydrocele. At one time, however, this was not admitted without limitation; and suppuration was, in many instances, anxiously sought for, being considered by some as the only way of obtaining a cure. “Union, (says Mr. O’Halloran) without suppuration, by an immediate coalescence, or by the first intention, is merely chimerical, and is opposite to the rules of nature. Inflammation (contrary to the received canon) is not the time for a reunion of divided parts: This happy minute follows, not precedes suppuration.” It was timidity, with regard to the prevention of suppuration, and want of knowledge of the powers of the animal frame, which so long retarded the progress of surgery, and prevented the improvement of its operations.
The remedies which we employ, with the intention of abating and removing the inflammatory action, are either general or topical.
General remedies are perhaps only useful, or have only a superiority over topical ones, when a general disease, or fever, accompanies the local inflammation. Topical ones are only to be trusted to alone, when the disease is entirely local.
The general remedies, are naturally such as tend to abate action in general, or to diminish the natural action; and, therefore, will consist of bleeding, cold, purging, sweating, nauseating medicines, and some of the agentes dissimiles.
Bleeding is justly considered as the most powerful, and the most useful of all those remedies; and, in many cases, is the only one which can accomplish a cure. The quantity of blood which it is necessary to detract, will be regulated by the effect of the inflammation upon the system, and by the previous condition of the person, with regard to strength; for those who are weak bear bleeding worst; and in them we cannot repeat it so frequently, as in the robust. Delay in them is, however, more dangerous; because the inflammation makes a more rapid progress, and, therefore, we ought sooner to push our remedies.
When the system is affected, in consequence of inflammation of vital parts, the general action is greater than when other parts are affected, and, therefore, bleeding must be used earlier, and with more freedom. Mr. Hunter observes, that when these parts are inflamed, the patient bears bleeding worse than when parts are affected which are not vital; but this observation must not be admitted indefinitely. When these parts are affected, the action is so violent, that the power cannot long support it; and, therefore, we must have early recourse to the lancet, and allow the blood to flow until the pain diminishes, and ceases to abate any more, and until the pulse becomes softer, and perhaps fuller. This is the time to stop; but, whenever the pain returns, or the pulse becomes hard, the orifice should be again opened, although we had bled only half an hour before. The system, in this way, is not weakened, nor the action sunk so low as to injure the power of recovery, which might be the case, were we to bleed too copiously at once. This remark applies, in a particular degree, to inflammation of the bowels; but it may also be extended to pulmonic inflammation; only, in this case, we can detract more blood at a time than in the other instance; because the system sympathises less strongly with the lungs, and, therefore, general evacuation will be longer of operating on the local disease. The same cause, however, makes the danger less; because the general action is not raised so high, and the part itself not being so delicate, can support the action longer, and, consequently, the danger is less. It is an established point, that no action can subside, or be destroyed suddenly, and the patient become free from disease. All morbid actions must subside, more or less slowly, and, therefore, bleeding ought not at once to be pushed so far as to produce fainting, unless the patient be very liable to faint. This sudden cessation of general action does not destroy the specific nature of the action which is going on when it is induced, but rather leaves the parts stationary, the tendency to morbid action still continuing, although the capability to act be suspended for a moment[3]. In place, then, of bleeding so as to exhaust the strength quickly, and endeavour, as it were, by the quantity of the discharge, to destroy the disease by one bleeding, it will be much better to bleed just until we produce the feeling of weakness to a moderate extent, and abate, to a certain degree, the pain and hardness of the pulse; stopping, whenever we find that we are not abating it farther, distinguishing, however, betwixt real abatement and syncope, or want of power to act and feel. We then repeat the evacuation, whenever the hardness of the pulse and pain return; and thus, perhaps in one day, and with infinitely more benefit, bleed much more frequently, and, perhaps, to a greater extent than is sometimes done in a week, by those who bleed more copiously at once, and repeat it seldomer.
Concerning the exact quantity of blood, which ought, in the different varieties of inflammation, to be detracted, I hold it, from the above principle, to be ridiculous to give any direction; because no general rule can be given, by which we may, a priori, determine the quantity. We are to bleed until we procure an abatement of the action; and to stop whenever this abatement ceases to be really progressive[4]. We are to renew the bleeding, whenever the action again increases, and stop, as before, whenever it is abated, remembering, that, after some time, a more sparing detraction will produce a greater effect, than a more copious one would do, in the commencement of the disease. It must also be attended to, that, owing to the weakness induced by the disease, and by the bleedings, we must, toward the end, bleed at longer intervals; for, if we continue to bleed in the same way as formerly, we would either kill the patient, or at least prevent the act of restoration from taking place; because we would thus diminish the power, or vital energy, which was to perform this act. Those, then, who order a certain number of ounces to be taken away, must reason upon probability, and prescribe less efficaciously, than those who direct no determinate quantity, but regulate their practice by the effects. It is equally foolish in those who order bleeding, pro viribus, and are satisfied with this until their next stated visit; because bleeding until fainting takes place, and not repeating it for some time afterwards, may be doing a great deal too little.
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.