If the explanation of the mode of adhesion in veins already given be correct, neither the propriety of bleeding, nor of the administration of mercury, as a rule, derives much support from a consideration of the pathology of the disease. Careful comparative experience is still wanting, before we can form a satisfactory judgment of the value of these remedies. The theoretical views upon which they have been adopted, are confirmed neither by the statistical records of cases, nor by the principles of sound physiology. The numerical evidence which we have in some instances, even tends to indicate an opposite plan of treatment.
At a period when puerperal fever was rife, forty cases, attacked with some form of the disease, "were treated without any bleeding or leeching, or without any attempt to induce the constitutional effects of mercury; and of these, only two died."[41] "In irritable habits, when the inflammation becomes more diffused," says Mr. Hunter, "bleeding should be performed with great caution: even a quick, hard pulse, and sizy blood, are not always to be depended upon as sure indications of bleeding being the proper method of the resolution of the inflammation; more must be taken into the account. The kind of blood is of great consequence to be known; for although it should prove sizy, yet if it lies squat in the basin, and is not firm in texture, and if the symptoms at the same time are very violent, bleeding must be performed very sparingly, if at all; for I suspect, that under such a state of blood, if the symptoms continue, bleeding is not the proper mode of treatment. If we had medicines which, when given internally, could be taken into the constitution, and were endowed with a power of making the vessels contract, such, I apprehend, would be proper medicines. Bark has certainly this property, and is of singular service, I believe, in every inflammation attended with weakness; and therefore, I conceive, should be oftener given than is commonly done."
In bleeding women suffering from puerperal fever during an epidemic, in which the disease frequently terminated in purulent deposits, I have occasionally seen an irregular transparent bluish layer form upon the surface of the blood, almost immediately after the operation; in consequence of this, a repetition of the bleeding was sometimes had recourse to, when the subsequent stages of the disease appeared to indicate that it had not been required. The transparent layer of lymph on the surface of the blood, may, in such instances, be only an indication of its tendency to separate into its different parts, as previously described. Large bleedings, under such circumstances, inasmuch as they tend to diminish the already enfeebled power of coagulation in the blood, may predispose to the infection of the system, and to the formation of purulent deposits. The influence of mercury upon the system, as illustrated in Case xxvi, may have the same tendency.
The action of mercury, so far as it can be traced upon the surface of the body, is certainly unfavourable both to union by the first intention, and to adhesive inflammation; and, inasmuch as the safety of the patient, after an injury or wound, depends upon the due performance of these processes, its effect upon the system must be regarded as of, at least, doubtful advantage.
When salivation has been induced, serum is poured out, and the texture of the gums is loosened and rendered spongy. When lymph is effused upon the iris, the action of mercury loosens its adhesions, and dissolves its connexions; it cannot, therefore, be supposed that its effect upon the system should render the union of divided vessels stronger, or the newly-formed adhesions in wounds, firmer.
The cases in which purulent deposits usually form, indicate a debilitated state of constitution. They are of much more frequent occurrence in large towns than in the country, and in hospital than in private practice. The depressing influences which give rise to erysipelas, or puerperal fever, will also predispose to the formation of these abscesses; and as scanty diet, loss of blood, debilitating surgical operations, and over-crowded rooms, have been found among the causes of the former, so may they be looked upon as favouring the production of the latter.
The Treatment of Inflammation of the Veins, in which purulent deposits frequently originate, is thus spoken of, after matured observation: "All the experience that I have had on the subject, would lead me to believe that, like erysipelas, it has its origin in a low asthenic state of the system, and that those persons are especially liable to it, who have been much lowered by hæmorrhage at the time of an operation, or by too scanty a diet afterwards. An operation is a shock upon the system, making a great demand upon the vital powers. The effects of this shock are often much aggravated by loss of blood, and a very scanty diet actually makes the patient more liable to some kinds of inflammation. Our mode of practice ought to be rather to sustain his powers by allowing him wholesome nourishment, and not to add to the influence of the other depressing causes, the still worse one of starvation."[42]
The lowering influence of mercury may be considered in a similar way. There can be little doubt that while, on the one hand, it favours the absorption of vitiated fluids, it may, on the other, render the system less able to resist the injurious consequences which they produce.
As many circumstances, besides mere debility, tend to depress the vital powers, so tonic medicines, and a generous diet, must not be looked upon as the only preventive modes of treatment. Each case that occurs in practice may present some peculiarity; in one case, the patient will be found to have previously suffered from diabetes; in another, from disease of the spleen; and in a third, from organic disease of the kidney; and, in each of these, a peculiar mode of treatment may be required.
The general management of this disease, after the formation of purulent deposits has commenced, is probably as little satisfactory as any that come under the notice of the surgeon. The whole character of the affection is characterized by what has been aptly designated as action without power. The excitement of the system will imitate all the acts of genuine inflammation, without any of its healthy results; and loss of energy will appear immediately after, or even arise in conjunction with, the first symptoms of increased action.