Bleeding, of all the general remedies, is the best; and, next to that, cold, and nausea, which may be considered as useful adjuvants. Sweating and purging are mostly to be used when particular indications present themselves, as may be understood from what has been already said. The first of these remedies, act chiefly by producing an universal abatement of action; and, of these, bleeding produces the most permanent effect on the body, and the most certain effect on the local disease. The two last are perhaps more useful, upon the principle of the sympathy of equilibrium, than that of abating action in general, which is only a secondary operation; and, therefore, they may be considered as remedies, acting rather topically than generally; for, according to this view, they act chiefly on the affected part. These two kinds of remedies may, in many cases, be usefully conjoined, producing thus a greater effect than either would do singly.
Before quitting this subject, it may not be improper to attend to the proposal which has been made, of exhibiting anodynes immediately after bleeding, in order to remove the pain. “The most effectual remedy for this purpose, (says Mr. Bell) is opium, which, when pain and irritation are considerable, as in extensive inflammations very frequently happens, should never be omitted. In large wounds, especially after amputations, and other capital operations, in punctures of all kinds too, large doses of opium are always attended with remarkably good effects. In all such cases, however, opium, in order to have a proper influence, should, as we have observed, be administered in full doses, otherwise, instead of proving serviceable, it seems rather to have the contrary effect; a circumstance which is perhaps the chief reason why opiates in general have been very unjustly condemned, in every case of inflammation.” That, in every case of inflammation, opiates are hurtful, is what no one can assert; and their utility will afterwards be fully manifested. But, that opium is useful, or even harmless, in the inflammatio valida, which we are at present considering, cannot be admitted; because daily experience, independent of every theory, proves, that, by their use, the general fever is increased, and the local action aggravated. Even given as a preventative of inflammation, after operations, anodynes are almost uniformly hurtful[9], producing restlessness, heat, and thirst, and afterwards head-ache, sickness, and frequently troublesome vomiting. I have therefore now, after almost every operation, laid aside their use, and find, that the diseased action[10], subsequent to the local irritation, runs its progress with much less disturbance, and is much milder, and shorter, than where anodynes have been administered; and, in general, the sleep is much more composed, and always more refreshing. I have therefore, after lithotomy, amputation, the extirpation of the mammæ, and after labours, in almost every instance, omitted them.
The local applications are such as tend either simply to abate action in the part, or such as tend to change its nature, by exciting a specific change, or such as act in both ways. The first comprehends cold, the second the agentes dissimiles, and the third topical bleeding.
Cold, applied directly to the inflamed part, is a most useful remedy, diminishing the action to a natural state; but, for this purpose, it must not be applied in too great a degree, otherwise we diminish the action so much, and so suddenly, (and, consequently, the power of the part) that recovery cannot take place. If we apply much cold to a healthy part, we sink its action so far, that it is irrecoverable; if we apply cold to an inflamed part, so as to diminish its action equally suddenly, and in the same proportion, we produce the same effect. Poultices of ice, or snow, are therefore highly dangerous; and even water, although it cannot be made nearly so cold as these. The same direction which has been given, with regard to the application of cold as a general remedy, ought also to be remembered, when we use it as a local application, namely, it ought to be carried just to such a degree, as shall diminish the morbid sensation, and ought to be so adjusted, as to keep the part nearly in its natural degree, or at least very little lower. For this purpose, it must be applied in moderation, repeatedly, and with assiduity; and not, as is commonly done, in a considerable degree at once, and renewed only at long intervals. Cold has been supposed to be useful as an active astringent, producing a contraction in the vessels; but it does not seem to possess any active power in producing such a state in the vessels to which it is applied. Where injury is taking place, from excessive action, cold, by abating it, may strengthen, and produce more natural contractions; but, when applied to a healthy part, it diminishes the action of that part, the blood is less forcibly circulated, and the part shrinks; it therefore stops active hemorrhage in the part on which it acts. When cold is applied suddenly, or to delicate parts, it excites an universal action, or contraction, or shrinking, from weakness; and, therefore, may likewise stop hemorrhage from distant parts. In many cases, when this shrinking, or temporary contraction, is suddenly induced by cold, it becomes converted into the natural muscular contraction of the part; thus, for instance, if cold be applied to the uterus itself[11], when torpid, after delivery, we find, that, after the first effect, or shrinking of the vessels, a more natural contraction takes place. If, however, cold be long applied, we find, that the contraction thus induced ceases, owing to the diminution of action which is occasioned by its continuance, and the original state of collapse, or shrinking, alone remains.
Blisters likewise act by simply abating the action of the part; but differ from cold, in requiring to be applied, not to the part which is affected, but to some other, with which it exhibits the sympathy of equilibrium; as, for instance, to the integuments of the thorax, in pulmonic inflammation; to the skin of the knee, in affections of the joint, &c. It is, however, necessary, when a general disease, or fever, is induced, that bleeding be fully employed, before we have recourse to blistering; because, if it be not, the inflammation, excited by the blister, co-operates to increase the fever, alongst with the original disease, which it has not had time to overcome, or lessen. Blistering likewise acts more effectually, when the local action has been already diminished, by previous bleeding. The size of the blister should be proportioned to the probable extent of the diseased action; at the same time, we must set bounds to this magnitude; because, if too large, they may not only produce, or keep up a general disease, but also, by lessening the action of the internal parts too much, and too quickly, they may prevent recovery[12]. It is therefore better to apply them of a moderate size, and renew them frequently, than to apply one too large at once. It must, however, be remembered, that inflammations of every part are not equally readily overcome in this way; and, therefore, one will require a larger blister than another; thus, the same quantity of inflammatory action in the brain, will be more difficultly subdued, than in the breast; and, therefore, we must apply, in that case, a larger blister. As it is the inflammatory action, induced by the blister, and not the discharge, as was once supposed, which is useful, it follows, that the same blistered place should not be kept too long from healing, or in the state of an issue, but that we ought rather to apply a succession of blisters; and this succession should be pretty rapid. There is indeed one case, in which issues are admissible, namely, where, from the nature of the inflamed part, or the peculiarity of the inflammation, if it be specific, or scrophulous, the progress of the action is very slow. In these cases, a rapid, and continued succession of blister would, doubtless, be most useful, but, from the duration of the treatment, would scarcely be submitted to: Issues, which are less painful, and less troublesome, are, therefore, generally preferred. We have an instance of this in many diseased joints.
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.