3 (J". P.) ^,|vwG <*)  Fk
INFLAMMATION
SYMPTOMS, CAUSES AND TREATMENT
PHILOSOPHICALLY CONSIDERED.
by
J. P. BATCHELDER, M. D.
      NE W-YORK:
HENRY G. LANGLEY, 5 ASTOR HOUSE,
     (BARCLAY-STREET.)
         1848. 
 
INFLAMMATION;
SYMPTOMS, CAUSES AND TREATMENT
PHILOSOPHICALLY CONSIDERED.
BY
J. P. BATCHELDER, M. D.

       ''iii i.a.>>
     —NEW-YORK:

HENRY G. LANGLEY, 5 ASTOR HOUSE,

     (BARCLAY-STREET.)

         1848. 
 
SYMPTOMS, PHENOMENA, AND EXCITING CAUSES

                              OF

                INFLAMMATION.
   So much has been  written  on inflammation that  it may  be
deemed quite  superfluous to present to the medical public any ad-
ditional remarks, but having seen no pathological views, from which
the indications of cure, and the methodus medendi seemed to flow
as natural, regular  and legitimate deductions, the writer proposes
for consideration, a theory which he hopes may contribute to remedy
that defect.  Whether  the endeavor will be crowned with success,
or the views presented meet with any favor, other than a candid ex-
amination, is to him quite problematical.

                        THE SYMPTOMS

of inflammation are redness, swelling, pain and heat.  " Rubor et
tumor, cum calore et dolore" in the pithy language of Celsus.
  Although the assemblage is  sufficiently  characteristic  of the dis-
ease, yet  no one of the group can be  considered pathognomonic*
Increased heat, as a positive quality,  is only a contingency, or an
occasional concomitant, and therefore, we shall regard it simply as
a mere sensation, and trace out the laws by which it is governed in
that relation.
   1. Redness arises from an increased determination and admission
of blood into the vessels of an inflamed part, and particularly such
as in a state of health circulate  colorless  fluids.   This  color is
not always very apparent in the early part of the disease ; but be-
comes more and more conspicuous during its  progress.  We look
upon it as the most important symptom ;—indeed, we deem it essen-
tial ; for upon it, or rather its cause, all the other phenomena depend.
Although sometimes present without inflammation, yet it is believed
that inflammation cannot exist when it is absent.   By the degree of 
4
INFLAMMATION.
redness we may judge with considerable accuracy of the stage, ra-
pidity and  violence of the disease ; the color of a part being a pretty
sure index to its circulation.

                   TUMEFACTION, OR SWELLING.

   2. To a certain degree swelling  occurs in all inflammations, in-
ternal as well as external, although not so apparent in the former as
in the latter.  Like increased redness,  it is generally  proportionate
to the intensity of the disease, but is, however, much modified in that
respect by the greater or less density of the part affected.
   An over-distention  of the capillary vessels  is the first link in  the
chain of causation.  As the capillaries like the hollow viscera, have
no power of distending themselves, the manner in which they become
distended, or over-distended in inflammation, may be more  properly
considered when  we  come to  discuss the modus  operandi of the
causes of that affection ; we shall therefore assume for the present
that by the influence of those causes, the capillaries of a part are in-
duced to forego their resistance, and that consequently, in accordance
with the principle in hydraulics, that fluids move in the direction in
which they meet  with least resistance, more blood  will flow into
them, and continue to do so until they become distended, and, in
fact, over-distended, in proportion to the diminution of their resist-
ance and the intensity of the vis a tergo.  When this over-distended
state has continued for some time, the pores which are analogous to
the sphinctered outlets of the larger organs, like them, under similar
circumstances, relax and allow the fluid contents to pass ; hence the
effusion of serum, albumen and coagulable lymph, which is  the
second link in the chain, and constitutes the main cause of the tume-
faction.
   Now the right performance of the function of a capillary or hollow
viscus, having an outlet, depends as much upon its mouth or pore
as upon the vessel or viscus  itself: in other words, to perform the
function properly, there must be a just equilibrium between the
force with which  the vessel or viscus contracts and that  with which
the  pore or sphincter resists.   When the distention is only moderate
or normal, the vessel  acts gently, the pore relaxes,  and effusion or
transudation  ensues.  For example :—when  the cutaneous capilla-
ries are only normally distended, we have neither more nor less than
insensible perspiration; and this degree of distention  we designate
by the figure 3 ;  if the distention be increased to 4, there will be sen-
sible perspiration; if to 5,  copious  sweating; if to 6,  the  skin  will 
TUMEFACTION,  OR SWELLING.
5
be dry and hot;  the sphincters or pores holding tight in consequence
of the over-distended state and violent contractile  efforts of the cu-
taneous capillaries, in which respect the analogy between them and
their pores and an over-distended bladder  and its sphincter holds.*
Beit remembered, that this distended state  of the capillaries of a
part constitutes one of the items, a small one  it is true,  which go to
make up the tumefaction; but the effusion of serum, albumen, fibrine,
and sometimes blood, are the principal causes.
   How does this effusion take place, and by what law is it governed
or regulated?   We come to the  principle.  If from any cause the
capillaries be suddenly or violently distended, or over-distended, and
consequently prompted to act violently, or inordinately, as in inflam-
mation, the pores, like the sphincters of the bladder or anus similarly
circumstanced,  act or resist no less violently and inordinately,  and
consequently  suffer no fluid to escape ; and this we conceive to be
the precise state of the vessels and pores  in  the incipient or early
stages of that disease, and is analogous to that of the vessels on the
surface during the hot stage of an intermittent, in which the skin is
dry.
  At this period, there is no other swelling than that occasioned by
the distended state of  the vessels of the part.   There is no effusion
of serum;  none of fibrine.  There is mere congestion.  How is the
effusion  produced 1   The vessels, over-distended—the pores, con-
stricted and resistant.  How then, we repeat, is the effusion produced?
The principle is this, that rest shall succeed to action.   This law re-
sults  from necessity  and  is consequently  universal,  reaching  and
controlling all vital movements ; hence, vascular contraction  is  fol-
lowed by the  spontaneous relaxation to which we have alluded,  and
which generally, is in proportion to the previous contraction.  There-
fore, in obedience to this law, the pore or sphincter, (see the  prece-
ding note,) as the case may be, which has been for some time resisting
powerfully and completely, the inordinate action of the vessel or vis-
cus,  and of course preventing the transmission of the fluids by which
the latter (the vessel or  viscus,) were distended, now in its turn fore-
goes its resistance, relaxes and allows the effusion of serum or fibrine
  * In an over-distended  state of the bladder, from long-continued retention, its
sphincter often relaxes, (not, however, until the expulsatory efforts [the vis a tergo
in this case] of the organ abate)and incontinence ensues; a circumstance which not un-
frequently misleads the unwary practitioner, and induces him to forego the introduc-
tion of the catheter, the only sure remedy for the retention which still continues, and
may cause the bladder to ulcerate, and the unfortunate patient to lose his life. 
6                        INFLAMMATION.
to take place into the inflamed part, or perspirable matter over the
whole surface as in the sweating  stage of an intermittent.   In both
<:ases, the  over-distended vessels  are thus relieved.   The final end
of this effusion is to empty the vessels ; in other words, to cure the
disease.   This is the method  of  nature and also of art; a fact of
which the practitioner should  never lose  sight.
   If this  want of equilibrium between the vessels and their pores
continue but for a short  time  and the effusion be but slight, resolu-
tion is said to have taken place, which is  one of the terminations ot
inflammation mentioned  by systematic writers;  but with  all due
deference, we are disposed to consider the effusion by which the ves-
sels are emptied and relieved, as the only legitimate termination of
that disease ; if indeed we  except gangrene.*   If the state of  dis-
tention continue several  days, the effusion may be considerable  and
of a mixed character; as serum, albumen, coagulable lymph or even
blood.  It constitutes the principal or main cause of the swelling,
the second symptom.   We are, however, ready to admit  that want
of absorption and the generation of new vessels, tend in some degree
to augment the tumefaction, and here it is proper to remark that the
formation of new vessels is often  exceedingly rapid, which with the
secretion  of pus, has been reckoned among the  causes of swelling,
and therefore, we shall proceed briefly to consider them.
   Let us inquire, in limine, why are these new vessels formed ]  and
why  is pus secreted ]  The effused fluids, if too great in quantity to
be absorbed, will remain an incumbrance greatly interfering with, or
wholly suspending the function of the organ or  part; therefore, to
get rid of them, the  suppurative process is instituted  by nature
in the simplest manner  possible  ; to wit, by the formation of new
vessels and consequent  organization of the effused lymph.   The
secretion of pus then is the final end of the formation of new vessels.
How are they formed ?  On this  point we shall hazard a conjecture,
which, like the theory  promulgated in this  paper,  was framed many
years ago ;  that a globule  of  blood escapes from a vessel, probably
the same which furnished the lymph, through which it (the globule)
  * When inflammation terminates in gangrene, the over-distended capillaries " re-
sist unto the death."  On the contrary, we  may have gangrene from an over-con-
stricted state of the capillaries, as in the gangrene of old people ; also in that from
interrupted circulation, &c. &c.  This constitutes the dry gangrene of authors and is
not preceded by inflammation.  In the first instance the vessels resist until they lose
their vitality. In the second they contract until they die.   The resistance and the con-
traction are both painful, and are followed by the same result. 
TUMEFACTION, OR  SWELLING.
7
makes its way, and thus forms a channel along which other globules
following close and in rapid succession, pass and continue to move
until  the track becomes a vessel;—similarly-occurring results take
place on every side ;—globules after globules  escaping from other
vessels,  pass  in  all  directions, till  channel  runs  into  channel,
and globule joins globule, when they will move in that direction in
which they are most forcibly impelled by  the vis a tergo which con-
tinues to urge them along, until the  channels are converted into liv-
ing vessels,  temporary or permanent, according to  subsequent  cir-
cumstances.  If the newly-formed vessels, or  the old  ones, which
according to some have become elongated and  made their  way into
the effused lymph, unite so as to carry on  the circulation in that sub-
stance, thus vascularized and organized, the inflammation is said to
have terminated by adhesion, which according  to our doctrine is in-
correct ; but when the quantity of coagulable lymph, or of other
fluids, is too large to admit of this kind of inosculation,  the adhesive
process  fails altogether, and the suppurative is instituted,  and  pus
secreted for the purpose already stated.  But  how  is pus, which is
said to be " altered blood," formed 1  How is the blood " altered V
Where are  we to find this modifying—this altering  power ? What
are the agents by which the suppurative process is commenced, car-
ried on,  and consummated ?  It is believed that the capillaries wher-
ever situated,  whether in the  areolar tissue, the serous or  mucous
membranes, or on the surface of the body, or a wound, will secrete
pus whenever they become invested  with a coating of coagulable
lymph, and that this is the main, if not the only contingency requir-
ed for altering the blood, and changing it into pus.   Upon this prin-
ciple, the primitive vessels, if elongated into the adventitious lymph,
will secrete pus.  But the business, so far as an abscess is concerned,
is probably done chiefly by the  newly-formed vessels, which are little
other than imperfectly animalized tubes, that can exert no other than
a mere altering influence upon the blood,  which converts it into pus.
   The first function then, of the newly-formed,  or the elongated por-
tions of the primitive vessels, when prevented from  inosculating by
the quantity of lymph, is the secretion of pus.
   According to the theory advanced, the disease terminated with
the effusion which emptied the vessels; therefore, suppuration is to
be considered neither  a termination of inflammation, nor a cause of
tumefaction, as a symptom. 
8
INFLAMMATION.
                              PAIN.

  3.  The third symptom of inflammation is pain ;  the cause of which
does not appear to have been explained in a very satisfactory man-
ner.  It was supposed to be owing to the swelling which put the ner-
vous fibrillae in the inflamed part upon the stretch;  but opposed to
this is the fact, that the pain and sensibility are often not at all com-
mensurate with the degree of tumefaction : for we frequently find a
part under inflammatory  circulation  exceedingly sensitive  when
there is little or no swelling;—and also, a part very much swollen,
as in dropsy, without either pain or increased sensibility;  the latter
is, indeed,  sometimes diminished,  although the nervous fibrillae are
greatly stretched.   Pain, in all cases, without a single exception as
we believe, arises from one of two causes : an over-constricted,  or
an over-distended  state  of the vessels.   The latter is their condition
in inflammation ;  and the  pain which results from  it precedes the
tumefaction from  effusion.  On account of the importance of pain
as a symptom of inflammation, and the  practical inferences to be
drawn from it,  we shall examine  whatever relates to it with consi-
derable care.  In  accounting for this symptom, the influence which
red or arterial blood (we use the terms synonymously) has in exalting
the sensibility of a part, seems to have been disregarded, or entirely
overlooked ;  but it appears to the writer of sufficient moment to be
entitled to  consideration,  and,  therefore,  he risks the   observation
that this connection between the sensibility of a part and the quan-
tity of arterial blood circulating in it,  is believed  to be so strict and
invariable that no  portion of the body through which red blood cir-
culates, is wholly insensible; and that no  part destitute  of red blood
is endowed with sensibility; and furthermore, that this holds as well
in the morbid as in the healthy condition  of parts—a consideration
that greatly enhances the value of the doctrine.   It  may therefore
be laid down as an axiom  in physiology  and pathology, that what-
ever diminishes the influx of red  blood into a part, or forces it out,
produces a corresponding diminution of its susceptibility of impres-
sion.   Fear and cold,  by causing  the contraction of the capillaries
on the surface, and consequently forcing  the blood out  of them, di-
minish its  sensibility;  hence the torpor and  insusceptibility of im-
pression which so uniformly accompany  their influence.   Joy  and
warmth, by relaxing the vessels,  and the consequent admission of
red blood, increase the susceptibility of impression.  Cordials taken
into the stomach produce the same effect.   If, in a doubtful case, we 
PAIN.
9
wish to determine the hardness of the pulse, or the existence of mat-
ter in an  abscess, we almost instinctively  rub  the fingers, or hold
them near a fire in order to exalt their sensibility of touch by solicit-
ing to them a greater quantity of blood.  It is needless to  multiply
proofs that the sensibility of a part is very closely connected with, if
not absolutely dependent upon  the quantum of blood circulating in
it, for every one must be acquainted with the fact, that the nails, hair,
bones,  cartilages, fibrous  membranes, &c, which, in their normal
state admit no red blood, are devoid of sensibility.
   When the capillaries of a part are distended beyond their healthy
condition, resistance is excited, and an effort to expel the distending
fluid ensues, both of which circumstances  are  productive of pain,
which, upon  the principle laid  down, is greatly  aggravated by  the
presence  of arterial blood, which has exalted the sensibility.  Again,
when the capillaries  are  contracted  much below their normal or
healthy standard, this over-contraction,  like the over-distention just
mentioned, is also the cause of pain.  In fact, these opposite states,
when extreme, produce sensations so nearly alike that it is quite  dif-
ficult, especially when an internal organ is  involved, to diagnoze be-
tween them without adverting to collateral  circumstances.*
   This  third symptom,  pain, is not only a matter of deep  concern-
ment to the patient, but of much consequence to the practitioner
when rightly and properly understood ;  for it greatly assists him in
determining what particular tissue or structure is affected.  In health,
every function is performed without  exciting  pain,  uneasiness, or
even consciousness of action ; when, therefore, either is experienced
the sensation  resulting from perception of change  indicates disorder
or disease.   Now, similar changes can take place in similar struc-
tures only;—pain or feeling being the perception of  change, it like-
wise follows that similar feelings can be experienced in similar struc-
tures only; and dissimilar feelings  in dissimilar  structures only;—
different sensations always indicating different organisms. Now,  the
mechanism of every structure is peculiar to itself; consequently each
tissue must have its own peculiar mode of acting, and of course its
  * The most serious consequences have often ensued when these  affections have
been wrongly diagnozed, which might have been readily prevented had the question,
whether the pain and other symptoms arose from an over-contracted or an over-dis-
tended state of the vessels of the part, been  fairly put,  duly considered, and fully
answered.  This matter, though important, and intimately connected with our sub-
ject, must be  passed over with this brief allusion,  which will be comprehended
by every practitioner of experience. 
10
INFLAMMATION.
own kind of  feeling.   The  final end of this arrangement is proba-
bly conservative, for we observe that the feeling of each part is that
which is elicited by causes adapted to derange its function, or disor-
ganize its structure, the uneasy sensation prompting us to procure
their removal.
  The fact that a great number of  feelings, which have been sup-
posed to arise from the peculiar properties of  the external cause or
agent, may be produced without any external  agent or cause what-
ever, goes to prove most conclusively, that the  immediate object of
perception is the vital change in the organ itself rather  than the
physical action of the cause  applied; therefore, it is quite immate-
rial to the surgeon, or practitioner of medicine, so far as the location
of  the  change is  concerned, whether an external or  an internal
cause be the agent by which it is effected.  As we cannot now go
into an argument to prove that feelings  are necessarily modified by
structure, we shall only allude to the fact that the same  sensation
may be produced by many different physical causes, which can be
explained in no other way than by supposing  that the action which
results from their agency is  so modified by the structure of the part
that it  (the action)  is and must be  the same in each particular in-
stance, hence the same sensation is produced.  Nausea, for example,
is excited by emetic drugs  of quite  different qualities ; and a great
variety of other physical agents, and very  often in the absence of all
such causes ; by the mere action of the stomach,  as in inflammation
of that  organ, or even a blow on the head, by sailing, whirling, or
by mental emotion, yet the  sensation is the same, however variant
the cause ; and we know where to locate the derangement, because
the stomach, from its peculiarity of structure, is the only organ  in the
body calculated  to  experience that sensation.   Besides the mecha-
nism of an organ as a whole, by which it is suited  to perform its des-
tined functions, there are, it should be recollected,  various textures
which enter into its composition,  and which,  if they could be  acted
on singly, without  any other being affected, would always give rise
to the same sensation.  For instance, if there be inflammation in any
part of the alimentary  canal, and the patient complain of a sense of
burning, we locate the disease mainly in the mucous  membrane;—
of a griping pain which goes and comes, we infer that the muscular
coat which contracts painfully, and relaxes spontaneously, is involved ;
—of sharp, shooting or lancinating pains,  we are  quite sure the dis-
ease has extended  to the peritoneal covering of the intestine, because
those are the sensations peculiar to serous membranes.  These seve-
ral tissues are so intimately  connected, that one can  seldom be much 
PAIN.
11
affected without causing  disorder in the others, which may be so
much  more intense in one than in the rest  as to obscure the sensa-
tions peculiar to them.  Again, take ophthalmia as another example :
—if the patient complain of a feeling as if a particle of sand were
in the  eye,  we know that the seat of the complaint is in the conjunc-
tiva ;—of spasmodic pains, we infer that the muscular tissues about
the organ are in trouble ;—of a sense of constriction or of resistance,
it is a sign that the sclerotic is involved ;—if there be great sensi-
bility to light, we suppose that  the retina,  and  perhaps the choroid
also, are in the same predicament.  If the  phlogosis be in the skin,
we shall hear of itching,* smarting, increased heat, or burning;—if
in the  muscles—of the sense of fatigue, of cramps or spasms, which
indicate inordinate  or  convulsive action; symptoms which  are  so
common in fractures, and not unfrequent in inflammatory rheuma-
tism ;—if in the ligaments—of the sense of contortion or distortion;
—if in the  stomach—of burning pain  and nausea;—if in the bowels
—of griping, &c. ;—if in the  rectum—of tenesmus;—if in a bone—
of ache, the only sensation  peculiar to the osseous structures ; if that
ache resemble the toothache, we judge that  the medulla  or its mem-
brane  is implicated ;—if accompanied with  a tensive feel—that the
periosteum is complicated;—if with a sense of weariness or lassitude
—that the difficulty has extended to the muscles.  If the disease af-
fect the fibrous  membranes,  which are  inelastic, there will be the
sense  of constriction or of tightness;  for instance, when the dura
mater  is affected,  the patient will tell you,  if particularly asked in
relation to  this point, that the feeling is that of constriction within
the scull and about the brains, as  if they  were tied up in something;
—or, when the pericranium is affected,  that the sensation is as if a
handkerchief were bound tightly about the head ;t—or the pia-mater
or arachnoid—that the pain  is lancinating, shooting ;\—streaming,
electric-like pains  belong to the  nerves of  animal life, a fact so no-
  * This sensation (itching)'is never experienced except when the cuticle is concerned,
hence it is always a sign that a wound or ulcer is healing. When the patient complains
that the sore itches, the intelligent surgeon knows that cuticle is beginning to form
on its margin.
  tThe sensations ascribed to the above-mentioned membranes often arise from di-
rectly opposite conditions of their capillaries.  In sick headache,  and the cold stage
of an intermittent,  those vessels are constricted ;  in the hot stage, and in inflamma-
tion,  they are over-distended.
   t Although the pia-mater and arachnoid are not fibrous membranes, yet I chose
to mention them in this connection,  on account of their being so generally involved
in the same category. 
12
INFLAMMATION.
torious, that no practitioner of the present day would venture to locate
the pain of tic-doloreux in any  other part than a nerve.
  The final end  of  this variety of sensation appears  to  be, as sug-
gested, the welfare and protection of the organ or structure in which
the feeling originated ; otherwise, what would prevent us from car-
rying exercise to an excess which  would destroy the muscles, if the
sense of fatigue, which is peculiar  to them, did not remind  us of the
propriety  and necessity of suspending our efforts ?   Or what would
save us from starvation if the physical and physiological changes in
the state of the stomach did not  excite  the sensation of hunger?
How should we know that a joint had been sprained or dislocated
if the ligaments  did not experience the sense of distortion, which is
peculiar to them.
                        INCREASED HEAT.
  4.  The fourth symptom, increased  heat, is by no  means  essential,
or even concomitant.   Although in external inflammations, the tem-
perature, as measured by the thermometer,  almost always exceeds
that of the  surrounding parts, it is now very generally conceded that
it seldom,  if ever, transcends that  of the blood in the heart, and is
never commensurate with that  indicated by the feelings of the pa-
tient.  When secreting surfaces are inflamed, there may be the sen-
sation of increased heat, with no actual increase of temperature, un-
less the disease  is so severe as  to stop secretion.  Regardless, then,
of temperature, we  shall consider this symptom as a mere sensation.
  Now the sensations of heat and cold appear to be almost entirely
confined to the  external surface of the body, because that alone is
subjected  to changes of temperature  which might be  detrimental.
If those sensations be  felt at  all  in  deeper-seated parts,  it is with
vagueness and  indistinctness; for in them they would be super-
fluous ; because the object, let it be remembered, is not the caloric
entering or leaving the body ; but the perception of physical change
in the part, hence the application or abstraction of caloric, the appro-
priate physical  cause of those sensations  is not at all  necessary to
their production ;  they may be  produced by any cause  whatever
which occasions a  distention or shrinking of the capillaries of the
skin, the part most liable to be affected by the excess  or defect of
caloric, and therefore designed  to  experience the sensations of heat
and cold.   From these premises, the conclusion is drawn that this
fourth symptom  of inflammation is seldom present unless the skin or
mucous membrane in its immediate vicinity is involved, and that it
always indicates a  distended or over-distended state  of the capillar 
EXCITING  CAUSES.
13
ries of the part, and gives intimation that changes are going on in
the tegumentary structures which  interfere with their  functions, or
threaten their integrity.

                    OF THE EXCITING CAUSES.
   Inflammation is produced by external agents acting mechanically,
chemically, or physically upon any part of the body ; or by causes
affecting the whole system ;  or it may arise spontaneously—that is,
without  any apparent cause.  We shall endeavor  to  trace out the
connection between the causes and the phenomena ; in other words,
to explain the manner in  which the former operate in the  produc-
tion of the latter, and the principles upon which their operation de-
pends, and also to  show, if we can,  that the facts and the theory har-
monize.   In the explanation of the symptoms  it was argued that
the redness proceeded from the admission of red blood into vessels
which previously circulated colorless fluids only ;  that the tumefac-
tion arose in part  from distention of vessels ; but  mainly from the
effusion of serum,  albumen, fibrine  and occasionally of blood ; that
the pain, modified  by the  structure of the part, and  heightened  by
the influence of arterial blood, resulted from the distention and over-
distention, and consequent resistance  of the capillaries ; that the
sensation of heat which was present only when some portion of the
skin or internal tegument was involved, was occasioned by an in-
creased determination of blood, to one, or the other of those tissues
by which  their capillaries  were over-distended, the  state common to
all vessels, subjected to the disease.
   1. How in accordance with the doctrine promulgated is this dis-
tention or over-distention  of the capillaries, the fans et origo, the sine
qua non  of all the phenomena of the disease  produced by causes
acting mechanically, chemically or physically 1   The blood, incom-
pressible as water, moves  through  the arteries by  an impulse  from
the heart, and makes an impression at the same instant like  a solid
upon  the capillaries in every organ, that is somewhat in proportion
to its own  momentum and their  resistance, which  (resistance) in
health is  supposed to be equable throughout the system, therefore, a
due equilibrium between  the impulse  and the  resistance is main-
tained ; but if a cause be  applied which takes off, or diminishes the
resitance of the capillaries in any  part, the blood, like other fluids,
moving in the direction in which it meets with least resistance flows in
and distends those vessels, which forego their resistance  and conse-
quently cease to oppose its admission even if the action  of the heart
be not increased ;  but if it be, the  impetus will be necessarily aug- 
14
INFLAMMATION.
mented ; and the distention in the same proportion greater and more
rapid.  In what way do causes of this class act so as to take off the
resistance of the capillaries in any part;  or induce them  to lessen
their  resistance and suffer themselves to be distended, or over-dis-
tended 1  The fluids contained  in the  capillaries, constitute  the
natural stimulus, which  prompts  them  to  action or  resistance*
When the vessels are healthy and their contents natural  in quantity
and quality, action and reaction, are duly balanced  and every func-
tion  normally performed.  Now, then, it  is an axiom  in medicine,
which has obtained since the days of Hippocrates, with whom it pro-
bably originated, and is acted upon by every practitioner in his daily
walks, that the stronger effaces the weaker impression.  If, therefore,
an impression be made mechanically, chemically or physically upon
a part which is stronger than that made  by the fluids on the inner
surfaces of their containing vessels, the latter will, in accordance with
this  axiom, which is in fact a law of system, cease  their resistance,
and  yielding, suffer themselves to be distended, over-distended, and'
stretched, until they are excited to resist  and  that painfully : and as
most of the exciting causes of inflammation belong to this class, and
are of a painful character, their modus operandi is accounted for in
that way.t  We repeat, the impressions made by all or nearly all the
causes of inflammation are painful and also external to the  vessels
of the part on which they act ;  therefore, upon the  principle  laid
down, they induce those vessels to relax and suffer themselves to be
distended.  If the cause be sufficiently powerful and the relaxation
sufficiently  extensive to bring the  vessels  of the heai't into an analo-
gous sympathetic relaxation ;  or in other words, to induce  the capil-
laries of that organ to do what has been done by those of the part to
which the cause has been  applied, i. e. relax and admit more blood
into  its texture by which  it, as  a whole, is stimulated  to  increased
action, the pulse  will become stronger, more frequent, full and per-
haps hard, and the blood be sent with greater force to all parts of the
body;  but finding less resistance in that, to which the exciting cause
has been applied, much more will be forced into it, and its vessels in
  * Upon this principle, rests the whole doctrine of counter-irritation.  If the exter-
nal irritant  make an impression, or excite  an  action, stronger than that going on
within the diseased part, relief may be expected to follow.  If otherwise, the symp-
toms, especially the pain, will be  aggravated ; the rules to be observed in order to se-
cure the desirable result, cannot  be considered in this place.
  t If the cause or agent be of an opposite character and make a pleasant or an
agreeable impression, provided it  be stronger than that made by the fluids within the
vessels, the result will be the same. 
EXCITING CAUSES.                     15
the same ratio over-distended and stretched, and  the inflammation
more perfectly  developed and aggravated.  If the vessels of the
heart do not sympathetically relax and that viscus do not, in conse-
quence, act with  increased energy, there may be  congestion  only  :
hence the  same  cause may produce congestion  in one case and ac-
tive inflammation in another.  Upon this principle  we explain the
fact that genuine inflammation so  often  succeeds to simple conges-
tion.
  2. Causes affecting the whole body.
  We have stated  that the  capillaries  receive  at the same instant,
over the whole body, the  impression of the blood sent by the  heart,
and that they, being the  antagonists of that organ, exert simultane-
ously in every part  an equable resistance to that impression, and
that in this way the uniform  distribution  of the circulating fluids is
maintained.  How then  is this equilibrium disturbed by causes af-
fecting the whole system  so  as to  induce inflammation ?  Cold and
malaria belong to this class and excite a general contraction  of the
capillaries  throughout the entire body, which is followed by a spon-
taneous relaxation commensurate in  extent and degree with the
previous contraction ; if under such circumstances any organ  or
part from predisposition, hereditary taint, disease, injury, age or sex,
be weaker then the rest of the system, its vessels, having less power
of resistance, will yield and be over-distended, an effect which will be
greatly enhanced by the  increased energy with which  the heart will
act in consequence of its own capillaries having simultaneously with
those of the other organs relaxed and of course admitted more arterial
blood into  its very textures as well as into its cavities.   This class of
causes sometimes act upon another principle.  If the cause, extensive
and powerful, be applied to the surface,  the vessels of some internal
organ, in obedience to the law that the stronger impression effaces the
weaker, may relax and become  over-distended and inflammation fol-
low, although it may not supervene until several days after the appli-
cation of the cause which has disturbed the harmony of the circula-
tory system.   Every practitioner's experience will suggest instances
in exemplification of this principle.
   3.  Inflammation may arise spontaneously ;  or without any  appa-
rent exciting  cause.
   In such cases, which  are  quite rare,  there is weakness or  great
readiness  in the capillaries of some part to relax and yield to the
distending influence of the fluid, which they contain  ;  hence causes
which are not sufficiently strong to excite consciousness of action in
                               2 
16
INFLAMMATION.
the mind of the patient or attention of the physician or friends, are,
nevertheless, capable of disturbing the equilibrium between the dis-
distending and resisting forces of the vessels ;—and by the subsequent
yielding of the latter, more blood is continually admitted until they
become over-distended and resist painfully, when all the phenomena
of inflammation follow in train.  I have not had time to pursue this
branch of the subject further ;  nor do  I deem it necessary, and  shall
therefore dismiss it with the remark, that organs to which, in the econ-
omy of the system, a greater quantity of blood is sent, are for the time
being more subject than other parts to inflammation induced in this
way.
          Of the Proximate Cause of  Inflammation.

By the proximate cause we mean :  "  That phenomenon in the body
or part, most immediately preceding the state which we call disease ;
and without which previous phenomenon the disease is not known
to exist." *   Two theories relating to the  proximate cause of inflam-
mation have been promulgated, which are diametrically opposed to
each  other.   On the  one hand, it  has  been urged  that  increased
action is the proximate cause : on the other, diminished  action ; and
in the maintenance and  vindication of both there  has been no lack of
zeal,  ability or ingenuity, on either  side.
   In  reference to the first we respectfully ask :  Does increased ac-
tion constitute  " that phenomenon which immediately precedes the
state  which we call disease, and without which  previous phenome-
non, the  disease (inflammation,) is not known to exist?"
   If the exciting cause induce contraction of the minute vessels, the
only mode of  increased action of which they are capable, the fluids
they contain will be forced out, and they, (the minute vessels,) will
in consequence be reduced to a state of comparative depletion ; a
condition utterly incompatible with the  existence of inflammation,
which requires as the very essence—the sine qua nan of the  disease,
an absolute distention, or over-distention of the capillaries.  Be-
lieving, however, that the very loest  method of getting rid of a  false
theory, is to establish one that is true, and particularly as we wish to
avoid even the semblance of aggression,  we shall push this point  no
farther;  but turn our attention to the opposite theory.
   It is admitted by all that there is  move blood in a part when  in-
flamed than in a  state of health:  and it is also affirmed by micro-
* The above is Parry's definition of the proximate cause,—the best extant. 
PROXIMATE  CAUSE.
17
 scopical observers that  that fluid moves  through the vessels of the
 part affected with greater rapidity than when the circulation is nor-
 mal ;  but these facts, if indeed the latter be a fact,  have no relation
 whatever to the proximate cause which relates solely to the manner
 in which the increased quantity of blood gets into  the vessels.  An
 agent, acting mechanically, chemically, or physically  upon any part
 of the system, which makes an impression exterior  to  the vessels
 stronger than thac made by the fluids within, will in  obedience to the
 law that the stronger effaces the weaker impression, induce them to
 forego their resistance ; and  yielding, allow themselves to be dis-
 tended, or over-distended until they  resist  painfully.  We have
 then  distention  of  vessels, the primary symptom ;  redness,  the
 second; and pain, from resistance, the third ; the trio, which consti-
 tutes the formal and technical existence of the disease__the assem-
 Wage  by which it is recognised.  Now what but diminished action
 could  have preceded this " state which we  call disease ? "  Had
 the  action of the capillaries  been increased, no such result could
 have followed, even by possibility :  neither could it have occurred if
 those vessels had not relaxed, yielded and suffered themselves to be
 distended  or  over-distended.   We  infer  then that the  proximate
 cause  of inflammation is a suspension of the normal  resistance; a
 relaxation ; a yielding ;  a diminished action of the capillaries of the
 part that admits, upon hydraulic principles,  of the inflowing of fluids
 by which they (the capillaries,) are  over-distended:  This  want  of
 action, this non-resistance, continues until  the distention has pro-
 ceeded so  far as  to  excite actual resistance  in the capillaries, and
 then, and not till then, can we affirm the existence of the disease.  The
action  of the vessels  is then increased.  This  increased  action, the
 final end and natural consequence of which is, not only to prevent
 the additional influx of fluids, but to force them out  of the inflamed
 part, constitutes the true vis medicatrix naturce ; for it  causes  or
 attempts to cause, and if successful  does cause, the  reflux of fluids
 into the general circulation, which is equivalent to an evacuation by
 art.  In both  instances the vessels are  depleted.  This  result (the
 depletion of the vessels,) we deem, as before stated, the only legiti-
 mate termination  of inflammation—whether brought  about by the
 efforts  of nature, by remedies, or the conjoined operation of both.
   It has been  asserted, that there  is  not  only more  blood in an
 inflamed  part, but that  it moves through it  more  rapidly than in
 health, and that there is, therefore an increased action.   Neither of
 these facts concerns the proximate cause ; the stage of the disease 
18
INFLAMMATION.
having gone by for that.   Relating wholly to  the proximate effect,
they confirm our doctrine.
   The excitin^ causes of inflammation, as we have shown in a for-
mer paper,  diminish resistance in the capillaries—venous as well as
arterial;—consequently, as much,  and even more blood will be ad-
mitted into  them, and transmitted through the inflamed part than in
health.   But  this condition of things cannot lasx long ; because the
fluids, changed in their chemical and physical properties, will be
forced in every direction upon vessels which have not been subjected
to the exciting causes, and therefore do not participate in the morbid
actions of the part.   Those vessels, thus acted on mechanically, by
fluids chemically  and physically altered, promptly set up a resist-
ance to the  vis medicatrix natures,  the  exertion of which is to force
the fluids out of the vessels of the inflamed part; a result which may
be, and most generally is, prevented by  the  aforementioned resist-
ance of the surrounding vessels.  A pause  now ensues; the  fluids
stagnate in the centre, around which, and  towards the circumference,
the vessels being distended to a degree which constitutes congestion,
relieve themselves by the effusion of fibrine,  with  which the blood
abounds during the phlogistic state.   This fibrine,  the  effusion of
which has depleted the vessels, becomes  organized, and furnishes a
barrier to the further  extension  of the  mischief.  Beyond said bar-
rier, serum is poured out in such quantities as to  occasion the cede-
ma  that often accompanies inflammation,  and evinces diminished in-
tensity wherever it exists*  For the foregoing reasons we have come
to the conclusion that decreased action is  the proximate cause of in-
flammation.

               iNniCATIONS  AND METHOD OF  CURE.

   It is undoubtedly the duty  of the practitioner to endeavor  at  all
times to prevent disease ;  but as this paper has respect to cure rather
than prevention, we shall omit to notice the indications which relate
solely to the latter, except to remark,  that those which pertain to
prevention look directly to the proximate cause;—the reason is ob-
vious, for without " that  phenomenon, the  disease is not known to
  * This oedema is very apt to take place as above described, in inflammations of the
larynx, and particularly about the glottis, and constitutes the principal cause of danger
in many of those cases, especially if conjoined with spasm of the muscles belonging or
appertaining to those parts.  We shall consider this effusion of serum in  connection
with another part of our subject. 
INDICATION  AND METHOD  OF CURE.          19
 exist;"—and indirectly to the remote and exciting causes, they being
 essential to the production of "that phenomenon," the causaproxima.
   As medical men, we must not, however, lose sight of the fact, that
 the remote and exciting causes, when present, tend to keep up the
 disease,  and therefore  have in such cases a  strict relevancy to the
 cure.  The first indication,  then, is to  remove them.  But as they
 are  often absent, and the disease apt to go on after  their removal,
 we do not regard  that matter as coming  fully within the  scope of
 this  paper, and consequently omit its farther consideration.
   Having  endeavored to explain  the manner in which  this over-
 distended state of the vessels, the proximate  effect is produced, we
 shall now  consider—1. How  it is  kept up.   2. The  method and
 means by which it is  removed.
   1. How is this over-distended state of the vessels—the  disease,
 (the immediate effect of the proximate cause) kept  up 1
   The action of the heart,  (whether increased or not,) with the elas-
 ticity of the  larger arteries, constitutes the vis a tergo—the power
 behind—which  continually and unceasingly forces  the blood along
 into the capillary vessels of the inflamed part;  and  so maintains and
 keeps up their over-distended condition. But why does not the blood
 pass through and out of them  as fast as it enters 1  Having briefly
referred to this  point in connection with  the vis medicatrix naturce,
 we shall proceed to consider it more particularly in relation to one
 of the indications of cure.
   It has been shown, that if a hollow viscus  having an  outlet,  or
 capillary having  a pore, be  suddenly distended, or from  any cause
 whatever made to act inordinately, the sphincter or pore, resisting as
 suddenly and violently, would hold fast and prevent the transmission
 and  egress of the distending fluid ;  thus in consequence of the vis a
tergo, constituted as described, on the  one  hands  and  the  resistance
of the pores  on  the other,  the over-distended state of the  vessels,
which  comprises the  very essence of the  disease, is  kept uj) in all
its intensity.   The  conflict is then  between the heart, the capillary
vessel, and the pore; or, more particularly, between the first and
the last.  And the practitioner  who has most skill in adapting reme-
dies  to the adjustment of these opposing agents and actions, will
oftenest succeed  in curing inflammation.
   To comprehend this matter  in extenso, it should be remembered,
that  the capillaries and pores on the inner and outer surfaces, as the
skin and mucous membranes,  and internal organs, as the liver and
 kidneys, are in a state of distention and resistance, hence the dry 
20
INFLAMMATION.
skin, parched tongue, constipated bowels, paucity of urine and bile>
which go to make up the tout ensemble of the symptomatic fever of
inflammation; or the phlogistic diathesis.  Now, the mere softening
of the skin, or the appearance of moisture on the tongue, its tip or
edges for example, indicates the yielding of the pores in those parts,
and foretokens a general relaxation.  They are,  indeed, the  har-
bingers of the diarrhoea, copious sweats, and flow  of urine, secre-
tion of bile,  &c, which constitute the crisis, so much reckoned on by
the older physicians.  Although the quiescence, or abatement of the
heart's  action precedes and  contributes to  the relaxation, effusion,
&c,  it should not be forgotten, that the perspiration when general,
in its turn, like blood-letting, relieves the heart, and is therefore the
precursor of permanent  amendment in inflammation as well as in
most fevers.  The same  may be said of the  other evacuations.
  In the normal condition, and under healthy action,  the pore or
sphincteiyfirst in the order of events, relaxes ; but in  inflammation,
for  wise purposes, this  order of events is  reversed.   If the pores
yield  while  the vis a tergo continues, the effusion of fluids from
the several kinds of vessels involved,  will  be so copious as to destroy
either the structure or function of the part or exhaust the patient;—
therefore, they (the pores) must not yield.   Shall the vessels forego
their resistance 1  if so, they  will be more and more distended by the
action of the heart,  until  they lose their vitality, and gangrene  will
be the result; therefore,  they must not relax.
  As our leading indication of cure flows from this  doctrine, as a
natural, regular, and legitimate deduction,  and the success of our
treatment depends mainly on the principles it involves, we hope to be
excused for attempting  to exhibit it free from obscurity, or risk of
misapprehension.
  Referring then to the urinary bladder, as furnishing the most famil-
iar and favorable example  for illustration, we say we can recollect
no instance  of retention  of urine in which the sphincter yielded and
permitted that fluid to pass  incontinently before that  viscus had be-
come fatigued (paralyzed as the common phrase is,) and ceased from,
or remitted  in some good degree  its inordinate expulsatory efforts,
thus affording a most happy elucidation of a law, certainly very gen-
eral, perhaps  universal: that the  sphincter or pore does  not  yield
prior to the abatement of the vis a tergo, or in other words, until the
equilibrium between  the action of the viscus and its sphincter, or the
capillary and its  pore is  restored.   The  reasons for this are indeed
quite obvious.   Soon as  this equilibrium is established, the sphincter 
INDICATIONS  AND METHOD  OF CURE.             21
relaxes and  allows  the  urine, as in the example adduced, to escape
through the  urethra as fast as it enters the  bladder by the ureters.*
So when the capillaries are over-distended and act inordinately the
  * What are the practical deductions from this doctrine in relation to the medical
treatment of retention of urine, one of the most distressing "ills flesh is heir to?"—
also in respect to other affections of the bladder and urethra?  They are, 1. Induce
the patient to refrain as much  as possible from all straining, or efforts of an  expulsa-
tory character.   2.  Bleed to  fainting (if warranted  by the circumstances of the
case,) which suspends for a time the action of the bladder, and the resistance of the
sphincter, and both may and often do participate in the spontaneous relaxation which
takes place in tho capillaries over the whole system when the patient recovers from
the syncope  induced by  the bleeding.   3. Give a full dose of opium which lessens
the sensibility of the bladder and its sphincter, and  likewise the action  of both.  In
retention there is not a more efficient remedy than opium, in a liberal dose, from two
to four or five grains, according to  the severity of the symptoms or urgency of the
case.   The warm or hot  bath  is often an excellent adjuvant, and in  connection with
the other measures prepares the way for the surgical treatment—the introduction of
the catheter, with which it will be well to commence, in most  cases, unless contra-
indicated.  In the early  part of the disorder simple exposure of the n*ked body to
the air, or dashing cold water on it by the pailful,  (causing capillary contraction) dis-
turbs the morbid relation which obtains  between the  bladder and its sphincter and
causes the urine to flow.  A similar course, so far as  voluntary  effort is concerned,
may be pursued, with propriety, in the treatment of most diseases of  the bladder and
urethra,  attended with difficult micturition, which are  always made worse by the
straining of the  patient, from  which he should be instructed to abstain as  much as
practicable and trust solely to the powers of nature, spontaneously and uncontrolla-
bly exerted.  Moreover it should be recollected that derangement of function gene-
rally precedes organic disease; and particularly in these organs, that form of malady
is often  brought on by the injudicious exertions of the individual, which more and
more disturb the function and of course  increase  the affection;  which in turn disor-
ders more and more the function and excites to more strenuous exertions.   It is, there-
fore, the duty of the  practitioner, especially in the incipiency, and  indeed through
the whole course of  these complaints, to caution and advise  the patient  on these
points, and he will have the satisfaction of finding, that if no cure is  effected, the
progress of the disease will be  retarded.  This doctrine has a no less strict and prac-
tical bearing on the functional disorders of other  hollow viscera, having sphinctered
outlets, as the uterus, rectum and stomach.   In obstetric practice it is of no  ordinary
importance.   The uterine contractions have for their  object, 1. To  open the mouth
of the womb.  2. Expel  its contents.   Now the os tincae holds the same relation to
the uterus as sphincters do to other organs with outlets; the law or principle of action
is the same in all, which is, if the organs  act gently or normally the sphincters relax;
but if suddenly or inordinately, they hold fast, or contract the more energetically;
and this  is just as it should be, for  great inconvenience and misery must follow, if
the sphincters yielded on every occasion, when the organs with which they  are con-
nected contracted suddenly or  violently.  If then the uterus should act irregularly or 
22
INFLAMMATION.
pores do not relax before  the  action of the  heart has somewhat
abated ;  and  this is as it should be, for if they relaxed, prior to the
abatement  of the action of the heart, there would be nothing to op-
too forcibly, the os tincte would, as in duty bound, like other sphincters, not relax or
suffer itself to be dilated ; but resist the more strongly in proportion to the inordinate
action of the womb, and of course retard or prevent the expulsion of its contents.
  The abnormal  action of that organ arises from two causes, viz.: the voluntary
efforts of the woman, and too great determination of blood to its substance.  1. The
cause which most frequently disturbs the equilibrium between the action of the womb
and its sphincter is the voluntary bearing down of  the patient herself.  Parturition is
mainly a function of organic life, and the power by which it is performed is of course
one of its attributes.  Now then, the voluntary power which belongs to  animal life,
should be neither invoked, nor allowed  to be exerted when it can be prevented, which
it can be to a considerable extent if  the patient be docile and is instructed and urged
to refrain from its exercise, a thing she will endeavor to do of her own accord, after
having realized the benefit during a few pains.  The primary object of uterine con-
traction' is  to open the os uteri  preparatory to the extrusion of the contents, and so
long as this process of dilatation is going on, or until  it is completed, all voluntary
efforts are  prohibited by the  nature of the case ; they are not  called for,_do no good
but much evil, for they aggravate suffering and retard labor by forcing the contents
of the womb violently against the sphincter, which causes it the more pertinaceously
to resist.
   When the os is fully dilated, it may be supposed that moulding and adapting the
presenting  part, and its transit through the passage would  be  hastened  if the pains
were increased by the voluntary  bearing  down efforts of the mother; but it must
not be forgotten that the process still  belongs to organic life ; and that therefore, all
such  efforts should be withheld, and  Dame Nature, who is  never thwarted with
impunity, be allowed to have her own way,  and the female attendants,  ever ready
to interfere on such occasions, with their advice, at least, made to stand by in silence,
and let her dameship have fair play.   When the presenting portion comes to press on
and distend the external parts, the process assumes a  mixed character;  the parts to
be dilated belong to animal life, but nature, true to her principles and purposes, has
ordained that the power, by which the distention of these parts as well as the expul-
sion of the child is to be effected, remain still an attribute of organic life ; therefore
the volitions of the patient must be excluded  as worse than useless.*   The policy and
practice inculcated should be pursued to the end of labor.  By so doing the suffering
is greatly mitigated and the danger of laceration dwindles to a point.  Having prac-
tised  according to this  system during the principal part of  his professional life, the
writer has known a great number of women  pass through even first labors with com-
paratively little suffering.  Some have declared, in one hour after delivery, that they
felt well, as if nothing had happened, and indeed, the whole getting up has been of
a piece equally favorable and satisfactory.   The principal  difficulty has often been

   * If encouraged or allowed to make much voluntary exertion, she may become too much debili-
tated or exhausted to complete the labor, hence the demand for instruments, for which there will be
very little need if the course recommended  be followed. 
INDICATIONS  AND  METHOD OF  CURE.            23
pose or prevent the effusion of fluids in such quantities as would, in
every instance, derange  or destroy the function or structure of the
part or organ in which the  disease  was located.   When the  vis a
 to keep them quiet, and exercise the degree of caution deemed necessary to secure
 them from the inconveniences and perils which so naturally cluster around the puer-
 peral woman.  This will be readily comprehended when it is considered that volun-
 tary efforts alone produce fatigue ;  hence the  fatigue, debility  and exhaustion, from
 the effects of labor, are to bo chiefly traced to the strenuous exertions put forth by the
 patient.   Women, in the savage state, practising upon this  principle, bring forth with
 little  suffering or inconvenience, and not unfrequently has the writer witnessed  the
 same thing in civilized life, even in primiparous cases.  The women, I know in  one
 and doubt not in both instances, refrained from  voluntary exertion, and so  far as
 child-bearing was concerned were on a level.  The chloroform,  by merely suspending
 volition, performs all that is  really required of it  as an anaesthetic  agent in obstetric
 practice.  After all, it is the fiat of the Almighty that women " in  sorrow shall bring
 forth  children," but the malediction neither demands that  she  should  suffer beyond
 what is necessary, as a punishment for having disobediently followed  the bent of  her
 own inclination, nor prohibits attempts to mitigate her sorrows.
  2. Too great determination of blood to the organ, and abnormal quantity of that
 fluid in the capillaries of the uterus, stimulates them to contract, and they do contract
 violently in order to force it out.  Now, what all the vessels of an organ do, that will
 the organ itself as a whole do; hence, the violent action  of the womb under such
 circumstances, and the simultaneous or consecutive action of its sphincter, which re-
 sists dilatation, and of course  prevents the expulsion of the uterine contents.  This
 state of things may be suspected when there are strong pains with little effect, other
 than distressing the patient,—when the pulse is full, frequent, or perhaps hard, with
 hot skin, thirst and restlessness ;  but it may be ascertained to a certainty by the touch.
 The os will then be found dry, tender, and unyielding,—often but little affected by  the
 pains,—sometimes contracting instead of dilating during their existence, notwithstand-
 ing their violence.
  When  the equilibrium between  the action of  the uterus and its sphincter is dis-
 turbed from this cause, bleeding until the pulse falters, or fainting approaches, equal-
 izes the circulation, removes the disturbing cause, restores the balance  of power and
 action between the viscus and its outlet, and the labor progresses with all due  expedi-
tion.   Tartar emetic in nauseating doses,  will sometimes do the same.  We not very
unfrequently find pregnant women near the time of confinement,  complaining of
 what are termed " false pains," which are no other than the contractions of portions
of the  uterus whose capillaries contain an undue proportion of blood,  that stimulates
 them to contract, while those in other portions having only  their proper quantity,  re-
main quiescent.  These are distinguished from the true pains by producing no effect
upon the os.   They disturb  and harass the patient, and sometimes  the young and
 inexperienced accoucheur, who does not exactly know what to make of them, or
 what to do to remove them; but he may derive comfort from the assurance that a small
bleeding or two, with some castor-oil, will equalize the circulation,  and consequently
 remove the difficulty. 
24
INFLAMMATION.
tergo continues, and the pores persist in their resistance, the capilla-
ries may resist until they lose their vitality, and we shall have what
is technically called gangrene;  but this never happens, as the result
of inflammation, without the concurrence of the  two contingencies
just mentioned.  If the pores yield there may be  disorganization,
but not mortification; if the vis a tergo cease prematurely, the ves-
sels may not be able to relieve themselves or even maintain their
vitality, and gangrene be the result; but it cannot be said in the strict
and legitimate sense of the  terms  that gangrene has been produced
as the consequence of inflammation.  To repeat, the conflict is be-
tween the vis a tergo, the capillaries, and their pores.  In health, the
last yield for the relief of the former; and the same order of func-
tion obtains in this disease if moderate; in which case the relaxation of
the pores unloads the vessels and cures the inflammation.
  2. The method  and  means by  which  this over-distention of  the
vessels is removed.
  This branch of  the inquiry embraces the indications of cure pro-
per ;  to the consideration of which we now proceed.
  From the foregoing principles and doctrines  it may be inferred
that relaxation of  the sphincter or pore is the  ultimate object to  be
aimed at  by the practitioner ; but to effect that  with safety, the  vis
a tergo must be diminished; until  that is done the sphincter or pore
should not relax, and probably never would relax  if the disease were
intense :  hence the  natural, regular and legitimate  deduction, that
to lessen the  vis a tergo so  as  to restore the equilibrium  between
the vessels and the pores, is the first indication of cure.   Now  the
vis a tergo cannot in every case, or indeed in a majority of cases be
so far diminished  as to secure this result without endangering  the
life of the patient; therefore a second indication is required, which
is :  to lessen  the  effect of the fluids impinging  against  the inner
surfaces of the capillaries, which excites them to inordinate action
and disturbs the  harmony of function between the  vessels and the
pores.
   If the foregoing were the only indications, it is obvious that even
they  could  not invariably, or under  all circumstances be  fulfilled
with  safety; therefore, a third indication  is demanded;  which  is:
to diminish or take off the resistance of the pores.   A fourth indi-
cation relates rather to the removal of consequences, than to the
cure  of   the  disease.    For example:  to  remove from  the  part
affected whatever  has been effused or secreted by which the vessels
have been  emptied, and  the  inflammation cured; but  which  if 
GENERAL  BLOOD-LETTING.
25
allowed to  remain might impair, interrupt or destroy the function
or structure of the organ or part.

  FIRST INDICATION OF CURE--THE DIMINUTION OF THE VIS A TERGO.

  In health the vis a tergo is kept  up by the  normal action of the
heart, aided by the elasticity  of the  arteries; and»in inflammation it
is rendered more  intense  by the  increased  action  of that  organ,
induced by the augmented quantity of arterial blood admitted  into
its  substance.  If this  increased action of the heart  be produced
and kept  up  by  the  augmented  quantity  and  perhaps  also, in
some  degree, by the vitiated quality of the blood thrown  into its
substance by the coronary arteries, reason and common sense alike
dictate the  propriety and necessity of lessening the quantity of that
fluid.
  The method, then, of fulfilling this indication is, 1. By the antiphlo-
gistic regimen, which comprises perfect quietude of body and mind;
pure air, abstinence, diet and  proper temperature.   When the phlo-
gistic diathesis prevails, digestion is disturbed;  chyme, badly formed-
assimilation, imperfect:  the  fluids, changed  and  unhealthy, make
a strange  and  novel impression  on  the inside of vessels and stimu-
late them to  irregular and  morbid  actions :  the withholding  of
food lessens the circulating mass ; diminishes the power by which it
is moved, and abates the  morbid  sensibilty which feels its impul-
sions ; results, which extend to organic as well as animal  life.  For
these  reasons,  nature and  theory both  suggest diet and regimen ;
and experience confirms the  suggestion ; the quantity and quality
of the  ingesta are  therefore matters worthy of consideration.
  2. By blood-letting ;  general and topical.

                     GENERAL BLOOD-LETTING.

  If the quantity of blood be considerably and rapidly diminished
by venesection, the vessels  of all parts, diseased  as well  as  others,
feel the effect; that is, they contract pari passu with the abstraction
of their contents :  If syncope, which consists in  an  universal and
extreme contraction of the capillaries, be induced, the  fluids in the
inflamed as in other parts will be forced out of them (the capillaries).
into the larger vessels.*
  * The practitioner who has ever bled a patient, laboring under conjunctivitis, to
fainting, must have observed that all the symptoms and phenomena of inflammation 
26
INFLAMMATION.
   Now this violent and universal contraction of the capillaries must
be followed by a spontaneous relaxation, or the patient will certainly
and quickly die.*   This relaxation is usually manifested first in parts
abounding with capillaries, as the  face, upper part of the chest, and
finally over the surface generally ;  hence we  find the  former  por-
tions and frequently the whole skin covered with perspiration before
the capillaries of the brain and heart, acting in sympathy with those
of the integuments, have relaxed.   A wonderful provision of nature
this  !  For exactly in proportion as the capillaries of the surface are
filled, those of the internal organs  will be  relieved of  a portion of
their contents ;  so that this relaxation  and consequent filling of the
cutaneous  capillaries  really and truly answers  for the  time  being,
and permanently, if kept up as it should be, all the purposes of an
abstraction  of blood.
   In order to make the most of this spontaneous relaxation, it  should
be borne  in mind  that it may be  increased  and prolonged much
beyond what is natural by the administration of a full dose of opium,
immediately on the recovery of the patient from the fainting caused
by the  bleeding.   By depriving  the vessels of a  portion of their
organic sensibility, the narcotic influence of the drug  co-operating
have disappeared, and that owing to the shrinking of the capillaries the diseased eye
had indeed become as bloodless and white as the other.
  * There is one case in which this contraction of the minute vessels is not followed
by the spontaneous relaxation of which we have spoken, and that is when the prin-
cipal artery in a limb has been tied, or the  circulation  through it wholly and  sud-
denly obstructed; contraction of the minute vessels necessarily ensues; a sense of cold-
ness is experienced and the temperature actually falls several degrees;  the surface
assumes the anserine appearance without the redness, and the hairs  stand off more
at right angles.  In a  few days the limb seems to resume its natural warmth  and
is  generally supposed to become preternaturally warm ; but this is apparent—not
real; it is the effect of the additional clothing in which the limb is usually invested ;
when that is removed and the two limbs exposed to the air, the  temperature of the
one still falls considerably below that of the other.t
  The great practical deduction to be  drawn from the fact that  this species of  con-
traction is not followed by spontaneous relaxation, is the propriety and necessity of
additional clothing to prevent too great contraction which might be productive  of
speedy gangrene;  and  of withholding warm  applications which might induce a
relaxation and over-distention of vessels that could not be sustained and mortification
would no less certainly follow.

  t The verity of these observations I  have recently had  an opportunity of testing in  a case in
which the external iliac artery was skilfully and successfully tied by my friend and associate Dr.
William H. Van Buren,of this city. 
GENERAL BLOOD-LETTING.
27
with  the  law of the system, carries this relaxation  much beyond
what is natural, and moreover holds the vessels  in that state  of
dilatation some ten, twelve or sixteen hours, or until a considerable
time  after the  specific effect  of the  medicine  may be  supposed to
have  ceased, during which the  patient is easy, and  comparatively
free from disease.  By this method  or mode of practice an inflam-
mation of a formidable character  may be  terminated at a blow ; a
dose of salts or castor oil  completing the cure.  If the symptoms
return, the same process should be repeated ; modified according to
circumstances.  Or if again ; an occurrence which we have seldom
witnessed, they must be met in a similar manner; or by such  other
means,  as the  judgment  of  the  practitioner  shall dictate, as the
warm bath, &c.  When the intensity of the disease has been  con-
siderably lessened and the powers  of the system enfeebled, the plea-
sant impression made by the physical influence of  heat and moisture
will induce a degree of relaxation that will remove the  pain which
still afflicts the  patient, and so prove a substitute for the lancet.
  This  relaxation is not confined to the vessels  of the  inflamed
part; but extends to all the capillaries and especially to those on
the surface ;  they  being more particularly subjected to the afore-
mentioned instrumentalities.  Into them  the blood will  flow, and
so long as it there remains, both the heart and the site of the disease
are freed from its influence; a  result  equivalent to  an evacua-
tion.  On this principle and under such circumstances, I am in the
habit  of resorting to the warm bath, as to venesection, so often as the
pain returns, and  therefore keep  the tub nearly filled in the  sick
room  that by the addition of  a small quantity of boiling water the
temperature can be raised to  the requisite degree  and the patient
immersed ; and on the removal of the pain, returned to bed ;  after
which anodynes, or sudorifics, as the  James' powder, with or with-
out opium  may be  administered in order to hold what had  been
achieved by the bath.   The foregoing practice may be pursued  in
croup, laryngitis, and other inflammatory affections complicated with
spasm or irritability, by the skilful practitioner.
  The number  of inflammations of a purely unmixed character, or
free from all complication with one or the other circumstances  just
alluded to, are very few—fewer indeed,  according to my observa-
tions, than is generally supposed.  In a large proportion of cases in
the great cities, all the symptoms are  aggravated and the disease kept
up, to the detriment and often danger of  the patient, by a  vitiated
condition of the circulating fluids—a condition which requires that de- 
23
INFLAMMATION.
pletion and narcotics should be blended—the one  for emptying the
vessels*—the other for lessening their morbid sensibility, which pre-
vents  their feeling and responding to  the impressions  made, not
only  by the momentum of  the circulating mass, but by its irritating
qualities.!
   Determination of blood to the head  does not preclude this prac-
tice of giving opium according to  the principles  laid down,  unless
the substance of the encephalon,  the nervous centre itself, is seriously
involved;  in  which case  it  may be questionable, owing  to  the fact
that the narcotic acts directly on the nervous system.f
   In  many cases analogous to those in which  the  warm  bath  is  so
useful, a  ligature  applied to  the  thighs near the  body,  sufficiently
tight  to interrupt the return of the blood through  the veins without
at all interfering with its passage in the arteries,  may be made  to
answer the purposes of an evacuant.  When  these ligatures can be
no longer borne on account of  the uneasiness  and discomfort they
occasion,  they may be removed and  applied  to the arms near the
axillae.  This use of the ligature will be recognized as being in per-
fect accordance with the  principles laid down.
   The safely and  success of  this practice, it will be  seen, depend
  * From observation, the writer is convinced that the lancet might be used with
advantage much more frequently than it is, in the large towns.
  tThe practice of giving opium after bleeding, which has been just  detailed,
so far as the writer is concerned, sprang from a remark of Darwin, that a  bleeding
immediately preceding an opiate, increased its efficacy.  The gentleman with whom
he commenced the study of medicine being a great admirer of that author, adopted
the suggestion, and often bled patients to whom he was about to administer an opiate.
Having frequently witnessed the salutary results of the practice, he also adopted it;
and from  repeated trials discovered that the principle and practice  were susceptible
of a much more extensive application than was at first apprehended—that in  fact
opium might be given, not only with  safety, but with the happiest effect in cases of
inflammation, if bleeding were premised,  in which, according to the theories then in
vogue, it would  have been utterly inadmissible.  Encouraged by success, and embol-
dened by a tolerably-enlarged experience, he came at length to use it in the manner
now recommended, and is unable to call to mind a single instance in which he  has
had reason to regret having done so.
  t During the last season, I was called to a lady whose case bore the strongest
marks of  determination  of blood to the head I had ever witnessed without positive
symptoms of grave cerebral disturbance.  I was never in more doubt, whether or
not to adopt the practice which has been recommended ; but confidence in the prin-
ciple prevailed.  The lady was liberally bled ; took a grain and a half or two grains
of opium and six grains of the pulvis antimonialis, and was, literally  speaking, well
the next day; a profuse perspiration  having followed. 
GENERAL  BLOOD-LETTING.
29
on the great and certain relaxation that takes place in the capillaries
over the system, and which is, as long as it lasts, equivalent to evacua-
tion.   In order to secure that result, the narcotic must be given in a
full dose.  It is not required that we  should always bleed to fainting.
A small bleeding of from eight to twelve  ounces will often  answer
the purpose, and that too in  many cases  in  which the opiate, but
for the bleeding, would have aggravated every symptom.  Again, the
vehement contraction of the capillaries throughout the system, during
fainting and the subsequent relaxation, will have so adjusted the
balance of circulation, even without the narcotic, that the vessels of
the diseased part will  be able to resist, for a  time at least, the vis a
tergo,  and  prevent the  intromission  of fluids in  an abnormal quan-
tity : hence the remission of  symptoms  which so generally succeed
a decided blood-letting.   But the capillaries of the heart, like those
in other parts, may, and often do, sooner or later, relax and re-admit
more blood, which causes its action to be renewed with so much
energy  that the vessels of the inflamed part, unable to resist the
impelling force  of the blood,  yield to  its impulse and are again over-
distended ;  a condition indicated by the recurrence of pain and suf-
fering, which calls for a repetition of the bleeding.   Several bleedings
may be,  in fact, required before the equilibrium between the  vis a
tergo, the capillary and  the pore is restored.  When that has  been
accomplished a free and general perspiration  usually breaks out.
  When  the case  is left to nature, this result is brought about in
another way.  The heart, the capillaries, and the pores experience
fatigue, and must have rest;  to obtain which they forego action and
resistance, and  the balance of circulation is restored.  The  morbid
phenomena  disappear,  and  nature is said to have  performed the
cure.   But why is she not always competent to  do this 1  Because
the heart with that " charity which begins at home," first supplies
itself with  arterial  blood through its coronary arteries;  the conse-
quence of which is, that  its own action is increased, by  which more
blood is thrown into its  capillaries, and its  increased action  is  thus
kept up so long as the mass of blood remains undiminished, or until the
capillaries (the antagonists of the heart), in every part of the body,
have relaxed and become filled with  blood ; a state which so far as
it goes, and so long as it lasts, is equivalent to an evacuation, because
considerable time must elapse before  the blood, thus distributed, can
find its way back to the heart.   That organ, thus acting, and re-act-
ing upon itself, will continue its augmented efforts until either the
capillaries of the diseased part have  lost their tone or vitality; or 
30
INFLAMMATION.
 until exhausted by its own over-action,  it has become too feeble to
 sustain the vital functions ;  hence, any sudden and considerable sub-
 sidency of the pulse in a case of inflammation, indicates either com-
 mencing gangrene, or approaching dissolution.  For these reasons
 we conclude that nature is not competent to cure all cases of inflam-
 mation.
   Venesection, as it is  skilfully or unskilfully employed, is potent
 for good  or  for evil.   It is therefore,  important that definite  rules
 should be laid down for determining—1.  When it should be resorted
 to.  2. When the proper quantity of blood has been drawn.   3.
 When the operation should be repeated.
   1. When is venesection to  be  employed ?
   In order to answer and  settle this  question, we must constantly
 keep in mind, that the specific object of blood-letting is to lessen the
 visa tergo by diminishing the quantity  of blood in active circulation.
 The fulness, hardness, and sometimes the frequency of the pulse, in
 connection with  other  circumstances of the case,  indicate  the pro-
 priety and necessity of bleeding.   Hardness and softness of bodies,
 are the  qualities which enable them to resist impressions; and in
 feeling the pulse, they are measured by the degree of muscular con-
 traction, which forces the finger against the artery, and the resistance
 opposed  by the vessel to that contractile  effort.  The pulse should
 be examined in both wrists, for it is, now and then, occasionally soft
 in one and hard in the  other ;  a condition which calls equally for the
 lancet, as if hardness prevailed in both.   If there be perplexity and
 doubt, it may be  well to feel the  pulse in other arteries, as the caro-
 tids, &c.   The pulse, however,  is not  always to be relied  on ; for
 there are cases in which neither its  hardness, tenseness, nor fulness
 is  very manifest,  and yet bleeding may be proper, and even neces-
 sary.   In such cases the heart must be appealed  to and examined.
 If that organ beat strongly, it  will be right and proper to bleed *  as
 suggested by Laennec,—a suggestion of great practical importance
 as  furnishing a criterion  for the  safe and proper use of the lancet
 under very perplexing circumstances.
   The condition  of the diseased  part may likewise assist us in de-
ciding upon the propriety of venesection ;  for the exalted sensibility,
  * If the action of the heart be strong, we may bleed, although the pulse is feeble,
and vice versa,—if the action of the heart be feeble and the pulse strong, we may not
bleed at all, or with great circumspection. I have been long in the habit of observing
this rule, and have never been misled by it. 
                      GENERAL  BLOODLETTING.                  31

 and  over-distended, stretched, and resisting state of the vessels of the
 part are declared and measured with tolerable accuracy by the feel-
 ings  of the patient,^pain on pressure, &c*   If the pain be severe,
 abstraction of blood is required for  relief;  but there  are cases in
 which neither the pulse, nor the state of the part, nor  the feelings of
 the patient,  actually demand the lancet;  yet, a small bleeding will
 nevertheless prepare  the system for other remedies ;  especially the
 antimonial  powder and opium ;  a dose of the latter,  preceded by a
 moderate bleeding, will frequently give  the most effectual relief,
 which but for that would  have  aggravated all the symptoms.
   2.  When has  the proper quantity of blood been drawn ]
   By discriminating accurately between a preternatural fulness and
 distention of the  heart and  arteries as  hollow organs, and  an over-
 distended state of the capillaries, as in inflammation, involving many
 vessels, we may often pre-estimate how much  blood should be drawn.
 When the accumulation is mainly in the cavities of the  former, (the
 heart and arteries,)  the abstraction of blood  is direct, and  likewise
 its  effect; consequently, a small quantity  will answer the purpose ;
 but when  the latter (the capillaries)  are implicated to any  consider-
 able  extent,  the  quantity must be larger, in order to cause them,
like the heart and  arteries, to feel  that the mass of  their  contents
   •Notwithstanding the tenderness of an inflamed part, the pain caused by pressure,
 although an almost invariable concomitant, is by no means peculiar to inflammation ;
 but is often connected with hysteria,  or other nervous affections.  In these, the ex-
 aggerated sensibility or tenderness, is  confined to the  surface, and is owing to exces-
 sive innervation of parts supplied by the peripheral extremities of the sensific nerves.
 Under such circumstances, pressure,  whether local or general, even if continued for
 some time, and considerably increased so as to affect deep-seated, or internal parts,
 Boon ceases to be felt or complained of, if the attention of the patient is diverted by
 conversation, or in  any  other way.    Pressure, to be diagnostic in  inflammation,
 should be made  suddenly on a point,  which forces the blood out of the vessels where
 it is applied, into those adjacent, and produces an aggravation of the pain ; why?
 because the vessels in an inflamed part are all in an over-distended, stretched, and
 resisting condition,  which is increased by the displaced  fluid, being forced  into
 those immediately contiguous, by which  they are still more distended and stretched,
 and the pain consequently aggravated.  When pressure, instead of being suddenly
 and lecally made, is applied gradually, generally, and equably, the pain will often be
not only not aggravated, but actually alleviated ;—for the pressure has, to a certain
extent, lessened  the quantity of fluid contained in the vessels.  Upon this  circum-
stance the utility of compression, as a remedy, depends.  But if the vessels be not
emptied by the  pressure, additional  inconvenience will be experienced from  it a»
well  as  from the distending  influence of their contents.
                                  3 
32
INFLAMMATION.
has been  lessened.   As this mode of judging  may not be  deemed
sufficiently accurate for scientific and practical purposes, the sensa-
tions of the patient, state of the pulse, action of the heart, &c, should
be taken  into the account as the principal and most reliable means
for determining not only  whether it is right and proper to bleed  at
all, but also when the suitable quantity of blood has been taken.
  The rule then, is to let the blood flow until the  pain abates  or
ceases ; till the pulse flags or falters or syncope is induced, which
last affords plenary evidence that enough  has been lost.   To that
point, in  severe  cases, should the  bleeding be carried—generally.
In such as are milder, the flow of blood may be stopped when the
changes in the pulse and feeling aforementioned are manifested.   In
cases of a mixed character, although some blood may and should  be
drawn, yet so much  only as will relieve  the fulness, or over-disten-
tion of the capillaries need be abstracted.  In such, and indeed in  all
cases in which it is practicable  the patient should  be  bled in the
erect or sitting posture, because  he will generally become faint just
when  the proper quantity of blood has been lost, which in mixed
cases will be small  compared with what it would be if the disease
had been  purely inflammatory.
   In every case and under all circumstances, in which bleeding at  all
is proper, it is desirable and  even indispensable that a certain quan-
tity of blood, proportioned to the severity of the disease, should  be
drawn before fainting is produced ; and as some persons faint very
easily, from fear or the loss of a little blood, it will be best  to place
the patient in a recumbent posture and allow him  to remain in it
until  the  quantity deemed requisite has been abstracted, when  he
may assume  the sitting or erect  posture and the blood still  allowed
to flow until  syncope  ensues.  By so  doing we  may economize in
the loss of blood and gain all the advantages, and avoid  the dis-
advantages which may accrue from a bleeding.   The question may
be here asked with propriety, why is fainting to be  considered one
of the criteria by which to determine how far the loss of blood should
be carried ?   In fainting there is, as has been remarked, a universal
contraction or shrinking of the capillaries, as well those in the inflamed
as in other parts.  Nature seems, so to speak, to take advantage of  the
enfeebled state or temporary quiescence of the heart to force the con
tents of the capillary vessels back into the larger vessels, and likewise
through the pores, which in health constitute a portion of the power  an-
tagonistic to that organ, but now, in consequence of its diminished  ac-
ion, forego their resistance; hence the  sweating which so frequently 
GENERAL BLOODLETTING.
33
accompanies or follows syncope, and which is often cold, resembling
that occasioned by the contraction of the capillaries in the moribund.
If the fainting be incomplete, a warm sweat may be the immediate
consequence.   For an  obvious  reason we should be in no hurry to
remove the syncope; as a general  rule the longer it continues and
the more slowly it goes off, the better.
   3. When should the bleeding be repeated.
   The return of the pain, after having been relieved by venesection,
is a sign of the renewal of the vis a tergo, and also of the resistance
of the capillaries and the pores; all  of which, as in the first instance,
call  for the  lancet—if slight, perhaps  for topical bleeding only.
When a repetition is proper, the quantity to be drawn is to be regu-
lated by the rules already laid down under the second  head.
  As to  a repetition of the bleeding, and also sometimes its first use,
it is  proper to remark that  nice discrimination  is  occasionally re-
quired, in  order to  determine whether  the local symptoms, espe-
cially when an internal  organ is concerned, depend on an over-dis-
tended or  an over-contracted state of the  capillaries; the  former
produced by  an augmented, the latter, by a diminished quantity, or
vitiated quality of the fluids.  The extremes here, as in many other
instances, seem  to meet—the sensations are  similar—to all ordinary
perception or discrimination, the same.   To make  the  proper dis-
tinction may be  difficult, but of vital importance ; because, if in the
first instance we stimulate, the patient may be destroyed; if, in the
last,  we deplete, the consequence may be equally unfortunate.  If
the pain and local symptoms arise from an exalted sensibility or an
exhausted or depraved state of the  fluids, narcotics, which diminish
sensibility, and consequently prevent the vessels feeling the impres-
sions made by the irritating qualities of the fluids, are the remedies
which  afford greatest, most relief.   It is on this account, in part, that
opiates are, as has been shown, so useful in the treatment of inflam-
mation.  The pulse, temperament of the patient,  condition  of the
system  and part affected,*  are the  sources whence  our conclusions
are  to  be drawn.
* See Note on page 31. 
34
INFLAMMATION.
                             CATHARTICS.

   Having  finished with the  consideration  of   general  bleeding  as
a  measure  for  the fulfilment of  the  first  indication—the  diminu-
tion  of the vis  a tergo—but  experience having  proved   that  that
most efficient remedy is not admissible in all cases, and that in those in
which it is proper it cannot be carried  to the necessary extent with en-
tire safety to the  patient, we are, therefore, constrained to look for other
means, the most  prominent of which are cathartics.   Like bloodletting
they act mainly as evacuants; not merely emptying the alimentary canal,
but depleting the vessels. As counter irritants they are sometimes bene-
ficial.  In all these respects, their modus  operandi* will be readily com-
prehended,  as coinciding with the doctrines  advanced by a recurrence
to them and to the axioms on which they are founded.
   As a cathartic, calomel is one of the best;  if not the  very best.
Besides its virtues as  an evacuant it possesses  the quality of  correct-
ing the secretions, and is therefore eligible in most cases, and pre-eminent-
ly so in those in  which  the secretions  are much  disordered  or  vitiated.
If the patient complains of a bitter taste, nausea, sense of weight or load
at the stomach, and exhibits a tongue covered  with a dark or yellow fur,
an emetico-cathartic, or simple emetic, followed  by cathartic medicines,
may be administered  with the happiest effect.    In many instances in
which the symptoms enumerated are present, an emetic which equalizes
the circulation will be of great service.   In our experience, that of Des-
sault, a little modified, is the best.  His emetic was one  grain of  tart.
antim. in  a pint of water taken at once.   This dose may have been suffi-
cient for a Frenchman;  but unless the Gallic medicine is stronger than
ours it will not, in a majority of cases,  emeticize an American, on which
account we direct six grains to be dissolved in as many table-spoonfuls
of water,  and one in a coffee-cupful of gruel or cold water,  given every
fifteen or  twenty minutes until the puking commences, which should be
encouraged by taking  large draughts  of some cold liquid immediately
after each time  vomiting.  The patient  must be instructed to imitate
spontaneous vomiting as much as possible, and abstain from all efforts to
assist in the operation—in other words, to let the medicine do its own work.f
  * See remarks on Counter Irritation, page 42.
  + In further illustration of the doctrine promulgated in these papers, we remark that
the stomach belongs to organic life, and having a sphinctered outlet is governed by the
same laws which govern all other organs of that class, as the bladder, etc.  When
that viscus acts gently the sphincter at the pylorus relaxes, and suffers the contents- 
CATHARTICS.
35
Emetics should be administered in the fore part of the evening, especi-
ally when we wish to break up the routine of a fever, or inflammation.
The reason of this will readily occur to all. As an emetico-cathartic, the
following compound has much to recommend it:

                    fy. S. m. hyd.              grs. xij.
                       Pulv. antimonialis,      grs.  vj.
                       Tart, antim.              gr-j-
               \Mix.  To be taken at once in a little syrup.

   The quantity of tart, antim., may be increased, diminished, or entirely
omitted, as the case may require.  This dose, if not sufficiently active as a
cathartic,  may be followed by salts and senna, or by salts only.  When
there is bile in the stomach the antimonial powder in doses of from six to ten
grains is a sure and gentle emetic. The pulvis antimonialis, having lost favor
with the profession, on account of alleged inefficiency, is rejected by some
and sparingly used by others.   Having employed it a great deal during
a large portion of his professional life, the writer holds it in high estima-
tion in febrile and inflammatory affections attended with considerable ex-
citement.   If preceded by bloodletting  and cathartics proportioned  to
the severity of the  case, it will seldom disappoint the expectation of the
practitioner.   The  failure to produce the desired  effect  has probably
arisen from one or more of the following causes—the bad quality of the
medicine,  too small doses, or omission to bleed  and catharticize pre-
vious to its administration.   Instead  of being small, the  dose should  be
as large and as often repeated as  the stomach will bear.   When  saline
cathartics  are indicated, or from  any cause preferred, the  following is
recommended, which occasionally acts as an emetico-cathartic :
                  fy.  Sulph. magnes.              §ij.
                      Sulph. sod.                  §i.
                     Tart, antim.             grs. iv.
  Mix and dissolve in eight ounces of water.  Dose, half or two-thirds of a
to pass, and no vomiting ensues ; but if it act irregularly or violently, as when an eme-
tic has been taken, the sphincter does not relax;  but holds fast, and prevents the pas-
sage of the contents in that direction ; and they are forced upward through the cardia,
which constitutes vomiting; thus far the operation  pertains to organic life and the
patient suffers little distress from it; but why should he abstain from voluntary efforts 1
Because the muscles of volition, the organs of locomotion, experience fatigue which
is peculiar to them ; therefore if they are not exerted the vomiting will produce little
or no exhaustion, or sense of weakness; indeed but slight disturbance in the system,
a result ofttimes very  desirable when patients requiring an emetic are much debi-
litated. 
36
INFLAMMATION.
wine-glassful every hour, hour and a  half, or two hours, until it begins to ope-
rate.
   In affections of the brain,  requiring active catharsis, the following will
act promptly and efficiently :

            ty. Aloes, calomel and gamboge, aa           3ij.
                Tart,  antim.,                          grs. vj.
                Croton oil,                             gtt.  ij.
  Mix—make  into a mass, and divide into 20 pills—one  to be taken  every
hour or two, until full  catharsis  is produced.

   We have extensively used tart, antim. in  the treatment of  inflamma-
tion—particularly pneumonia in its first stage.  Although  of no  great
value in pleurisy,  its use is not prohibited when inflammation in the lung
has extended  to the pleura.  The  writer's method of giving  it,  in that
disease, is to begin with a quarter of a grain once in  twenty or thirty
minutes, until two doses have been taken, when half a grain should con-
stitute the third dose, which is to be repeated in half  an hour; at  the
end of the next half  hour a grain  should be  administered.   If given at
such  short intervals, the stomach and intestines soon lose  their suscepti-
bility to its impression, and seem not  to  be at all affected, even by  enor-
mous  doses.*   As  soon as the disease seems  to  be  pretty decidedly
  * Connected with the repetition of emetic medicines, particularly tart, antim., is a
fact of considerable practical importance : If a full, or rather over-dose of that article,
or of ipecacuanha,  (and perhaps of most other emetic drugs,) is given, and several or
many repetitions are required, the succeeding doses may be regularly lessened, say
one-fourth each time, with no diminution of effect.   The writer has known a patient
in the habit of taking ipecac, as an emetic, to  be at last as effectually vomited by one-
sixth of a grain as by twenty at first. In the treatment of all such diseases as require
frequent vomiting, we may avail  ourselves of this  principle.   On the other hand, if
we commence the use of these articles in minute doses, and repeat them at short in-
tervals, the  system will soon lose its susceptibility to their peculiar stimulus, and the
dose may be increased ad infinitum, almost, without any appreciable effect.  If repeat-
ed every twenty or thirty minutes, the  dose may  be doubled every other time, until it
becomes very large ; and yet no emesis or catharsis follows.  Augmented thus, as by
the rule of geometrical progression,  the action of  the heart is  much  lowered both in
force and frequency, and the inflammatory affection disappears, as suggested in the
text—why or wherefore we cannot exactly tell.   In the administration of  narcotics,
particularly opium, the same principle holds.   In some cases, the long-continued use
of remedies of this class is necessary.   As in the former example, the  system loses its
susceptibility for their particular impression, and  the  dose must be  increased  to  a
frightful extent; nor is this all—there is great danger that the habit, dreadful as it is, of
opium taking, or rather opium eating, will be  formed, and then the fatal drug cannot 
            SECOND AND THIRD INDICATIONS OF  CURE.         37

checked, or subdued, which it will be in two or three days, the medicine
should be discontinued altogether  or partially, as the case may require,
and mercury given, which will prove much more beneficial in the second
stage than antimony.  If the  disease has passed the first stage the anti-
mony should be withheld and the mercury given.

               SECOND AND THIRD INDICATIONS  OF  CURE.

   The second indication is: to diminish the impression  made upon the
capillaries and pores by the impulse of the fluids impinging agamst their
inner surfaces and the effect of that impression.   The third indication is,
to lessen or take off the resistance of  the pores.
   As these indications are so intimately connected, and the remedies em-
ployed for their fulfilment so analogous, we  shall consider them together.
   It will be readily comprehended how lessening the action of the heart
weakens the impression of the fluids upon the capillaries  and the  pores,
and so contributes, as far as it goes,  to fulfil the second indication; and
also how that which weakens the forementioned impression will likewise
lessen or take off the resistance of  the pores, which  constitutes the third
indication ;  without the fulfilment of which,  it is believed, that no inflam-
mation of much standing will be cured.
   That abatement of the momentum by the abstraction of blood is not
of itself capable of  preventing the morbid  impulse, or wholly obviating
its effects, is clear from the fact that  the vessels contracting pari passu,
with the abstraction of their contents, are in  perpetual contact with them,
consequently the  impulse  must be made and  felt in  proportion to  its
force and the sensibility of the vessels; hence the necessity of the se-
cond indication which is to diminish the impression  and its effect.   It is
be dispensed with.  It is of great importance to avoid these consequences, which may
be done by making the first dose considerably larger than is demanded  by the exi-
gencies of the case, and each succeeding one less and less : suppose a case which will
probably require the repetition of an anodyne two or three times daily, and that forty
drops of laudanum is quite sufficient to produce the desired effect—fifty-five or sixty
instead of forty should be administered at first, and each subsequent dose lessened one
drop, perhaps two.  In this way the dose  will be  continually getting smaller and
smaller, while the effect remains the same, and the destructive habit is  not formed.
If the dose (40 drops) be given in the usual manner,  after a short time the system,
having lost its susceptibility to that dose, will not respond, and the quantity must be
increased in order to secure the effect, and ten drops are added ; in a few days another
addition must be made, and another, and another; and so on, until half an ounce, in-
stead of 40 drops, is demanded; and what is worse, even though the disease is re-
moved, the patient is cursed with a habit more dreadful than death itself. 
38
INFLAMMATION.
well to remember that the fulfilment of this indication contributes to that
of the third; for if we lessen the force and effect of the impulse, the
sphincter or pore will, as we have endeavored to show, relax;  and fur-
thermore, it may be proper  to remark in this  place, that  although we
have made three distinct indications of cure, they are so closely, naturally
and  philosophically connected that they almost  necessarily resolve them-
selves into one, viz., the abatement of the force and effect of the impulse
that being done the pores will relax and the vessels be emptied or deple-
ted and the cure accomplished.  The medicines adapted to the fulfilment
of these indications are of two  kinds—such as  act on the system gene-
rally, and such as act  locally on the part affected.  The former, by
equalizing the circulation, diminish the impulse; and some  of them, into
the composition of which narcotics enter, lessen  the effect of that impulse
by obtunding  the  vascular  sensibility.  Belonging to  this class are su-
dorifics—medicines of great importance, and by no means to be dispensed
with; the best of which is the antimonial powder, either alone or com-
bined with opium, by which  its efficacy is in many instances increased—
especially if the rules laid down have been observed.  The Dover's pow-
der,  by itself, in as large doses  as the  stomach will  bear,  or combined
with the pulvis antimonialis, will be found  of great  utility.  Instead of
the Dover's powder the writer has often substituted  one  composed of
opium, camphor and ipecac, each one part, and  nitrate of potash two
parts; a preparation which certainly adds considerably to the efficiency
of the antimonial powder.   The dose may be regulated by the quantity
of opium required in each individual case.
   The  old-fashioned  compound,  the  spiritus Mindereri, is a  valuable
remedy;  but which often fails from not being rightly administered.   It
should be given  warm, in ounce doses,  every hour or two, until the per-
spiration appears.   The patient ought to be kept in bed with more than
ordinary  covering and made to drink freely of warm  liquids.   If there
be much irritation, laudanum, or the elixir paregoric in appropriate doses
may be added from time to time.   Instead of being given alone, it may
alternate with the  sudorifics before mentioned, in  which case it must be
less frequently repeated.
   The colchicum antumnale  is often employed with advantage, especially
after bloodletting.   Combined with the digitalis, it is a tolerable substi-
tute  for the lancet  in subjects not plethoric or athletic.  By reducing the
frequency and subduing the force of the heart's  action,  and promoting
secretion and excretion, they cooperate with other evacuants in fulfilling
the first indication; and by their narcotic influence are more capable of
contributing to the fulfilment of  the  others.   Calomel as an  alterant, 
TOPICAL REMEDIES.
39
 either by itself or combined with the antimonial powder—two grains of
 the former with four or six of the  latter may alternate every fourth or
 sixth hour with the colchicum.   In severe cases as in croup, laryngitis,
 etc., calomel must be  given more frequently and in larger doses, with a
 view to its specific effect, or to the changes it is supposed to produce in
 the blood.*  When colchicum has produced its specific effect, j even in a
 moderate degree its use may be suspended and the sudorifics continued.
 Digitalis, acting as a sedative, is a medicine of considerable power.  Re-
 ducing the frequency and subduing the force of the  heart's action, hke
 venesection, it diminishes the  vis a tergo and the impression ; and in con-
 sequence is adapted to the fulfilment of the first and  second  indications,
 but must  not in urgent cases supersede the  use of the lancet.  How
 much effect the  foxglove has on the capillaries and  pores, independent
 of  its influence on the heart, is difficult to determine.  Its narcotic and
 particularly its sedative powers, are  too  considerable to  be overlooked.
 The forms of inflammation in which  the writer has employed  and found
 it most useful, are pleuritis and meningitis.   In all chronic inflammations,
 hke colchicum, it will be found most beneficial when  the urine contains
 an  undue proportion of lithic acid or albumen ;J without one or the other
 of these contingencies neither  of those medicines will  be of much service.
 If the urine  be  merely turbid,  or incline  to a bloody appearance, as it
 sometimes does in chronic inflammation and in dropsy, very satisfactory
 results may be expected to follow the use of the digitalis.

                        TOPICAL  REMEDIES.

  The second class of remedies  for the fulfilment of these indications
are those which act locally ; the object of which is to diminish  the action
of the vessels and lessen or take  off  the  resistance of the pores  in the
diseased part.  Their use presupposes  the employment of such general
remedies as may have been required.
  * The writer, judging from his own observation and experience, feels warranted in
saying that very few cases, if treated on the principles inculcated in these papers will
require or even justify the use of calomel to the extent deemed  necessary by many
practitioners.
  t By the specific effect of  colchicum, purging is not meant, that being unessential
to its peculiar influence as a therapeutic agent; but may be looked on rather as a
sign of its having taken effect.   In  fact  its purgative operation  seems not to differ
materially from that of other cathartics.
  t In all cases of pneumonia, and i n most cerebral affections, the state and condition
of the kidneys, and of their secretion, should be inquired into with great care. 
40
INFLAMMATION.
                       LOCAL BLEEDING,

By cupping and  scarifying, or by leeching, stands at the head of  this
class.  Whatever causes the vessels to act  less violently, or gently, will
induce the pores to relax.   By directly depleting the inflamed  vessels
topical bleeding lessens the  cause of their distension or  over-distension,
by which their efforts  to expel the contained fluids, or resist their dis-
tending force, will be rendered less intense as may be inferred  from the
mitigation of  symptoms which follows this  mode of depletion, and  is
commonly more marked if preceded by the general remedies which have
been recommended.   Moreover, local abstraction of blood frequently re-
duces the action  of the heart; lowers  the sensibility  of the  vessels;
diminishes the impulse and its effect, and contributes  in all these ways to
restore the equilibrium of action, without which the  pores will not relax
and allow that effusion of lymph and serum which empties the vessels
and completes the cure.  In producing relaxation of the capillaries and
pores, this method of bleeding acts upon another  principle besides that
of depleting the vessels.
   By  assuaging  pain  and mitigating suffering,  it is  equivalent to a
pleasing  impression and therefore causes  relaxation ;  pleasant impres-
sions induce relaxation, disagreeable impressions excite contraction and re-
sistance, therefore in the treatment of inflammation, our applications should
be made in accordance with one or the  other  of  these principles.  On
account of the pain or irritation occasioned by cupping and scarifying
leeching is preferable in superficial inflammations.   When deeper seated,
or when internal  organs are involved, the former is to be preferred.   In
whichever way the blood is drawn, the quantity must be regulated by the
judgment of  the practitioner; the constitution, age and  circumstances  of
the patient, and the effect of the depletion being taken into the  account.

                      EXTERNAL APPLICATIONS.

   The solution of the  acetate of lead has  been employed  time out  of
mind, as an external local remedy, and in many instances with probable
advantage.  Although much used as it has seemed rather from imitation
and habit, than a settled conviction of its real utility, it may be as good
as almost any thing else with which we are acquainted.   With laudanum
or opium  superadded, it   certainly  has  a  soothing and consequently
beneficial effect; but whether it is any more  useful than water  with the
aforesaid additions is somewhat questionable.  The  efficacy of saturnine
applications has been attributed to a sedative power which they were sup-
posed to possess.   If they really had  any such virtue, they would be en- 
EXTERNAL APPLICATIONS.
41
 titled to  great  consideration.   Could they lessen sensibility or vascular
 action, they would diminish the impulse of the fluids and its  effect on the
 vessels ;  but it is to be regretted that the testimony of the  profession is
 not very decided in their favor.
   The solution of the acetate of ammonia, is an excellent application and
 may  be used like the foregoing, with or without opium or laudanum.
   Evaporating liquids, or such as produce cold, as ice-water or pounded
 ice, may  be applied.  The  latter,  on account of the absorption of the
 caloric of solution,  (140° Fah.) is potent for good or for evil;  we are
 therefore bound to consider in this place, the principle upon which cold,
 as an antiphlogistic remedy, acts.   Causing the contraction of  vessels
 subjected to its influence,  it may be resorted to before the  action of the
 heart has been roused, and while  the local  contraction which it induces,
 is able to resist effectually the vis  a  tergo :* but when the vessels have
 become over-distended, and the vis a  tergo so strong, that the contraction
 produced by the cold is insufficient to force the fluids out of the capilla-
 ries of the part, the pnin will be aggravated  by cold applications.   After
 bloodletting, catharsis, etc., by  which the heart's  power  and action are
 lowered, they may be very proper and  useful, but if  the powers of life
 have  been too  much exhausted,  such applications may produce a degree
 of contraction incompatible with the vitality of the vessels and gangrene
 ensue.   The principles laid down in a former part of  this paper in rela-
tion to pleasant or unpleasant  impressions come in  here most happily.
When applications of low temperature are grateful to  the  feelings of the
patient, they are proper ;  if  disagreeable, they are improper and should
give place to such as are warm.f
  * Hence the utility of cold water applied immediately after a sprain or bruise, or the
infliction of a wound by accident or by design, as in surgical operations. For many years
past, the writer has been in the constant habit of using cold  water after his operations,
as soon as the plasters have had time to become well set, and to continue it for several
days, say five or six.
  t In making applications to an inflamed eye, even this rule should be followed with
some caution.  In general  they  had  better  he tepid  than warm ; when  the latter
are  employed, it  should be  only for a few minutes  at a time.  The objection to the
long-continued application of poultices  or fomentations  to the  eye, grows out of the
anatomical structure of that organ.  In that  form of disease called " morbid  sen-
sibility  of the retina," the writer has found that cold water to the eyes always keeps
up or aggravates the difficulty; so much so, that he does not allow patients affected with
it, to wash the eye at all, nor in bad cases, the upper part of the face, much less to let any
get within the lids.  In  such cases, patients are in the habit  of applying the cold water
to the eyes freely, and not unfrequently open them when submerged in it, and  they 
42
INFLAMMATION.
   These principles furnish an  infallible rule respecting the temperature
of such appliances and settle the mooted question, whether lotions, poul-
tices, etc., to an inflamed part, should be cold or warm.

                       OF COUNTER  IRRITATION.

   In the  deeper-seated  inflammations, and  especially those  which in-
volve internal organs, great benefit may be derived from  stimulating ap-
plications ; but for want of a  correct knowledge  of  the principle upon
which their utility depends, it is to be feared that more hurt than good is
not unfrequently done by them.  The principle is—the stronger external,
effaces the weaker internal  impression.   In  the  treatment of perhaps
every case of deep-seated or internal inflammation, there is a " blistering
point"—in other words, a time when irritating or stimulating applications
should be made;  a condition which cannot be recognized with certainty
without a correct understanding  of the principle on which rests the utility
and safety of those applications.  The object of blisters, rubefacients, etc.,
is mainly  to relieve pain or uneasy feeling.  The pain  of inflammation, as
we have seen, is  caused by an over-distended or  resisting state  of  the
capillaries.  If those  vessels can be induced to relax, the pain and  suffer-
ing will cease.   Now, if the disagreeable impression made by the blister,
which is external, be  stronger than that  made within by the  fluids,  the
vessels not feeling the internal impression, relax, and  the pain is relieved
—entirely, if the relaxation be complete.   If  the  impression of the blis-
ter be not, however,  stronger  than that made by  the fluids within,  the
symptoms will  be aggravated ; there may,  indeed, be no vesication, be
cause the internal is stronger than the external impression.  The aggra.
vation of the symptoms is explainable in the following manner : the  im-
pression of the blister has been  sufficiently powerful to induce the ves-
sels to relax or forego their resistance; but the vis a  tergo has not been
suitably diminished, of course the relaxed vessels will be again crowded,
and as much over-distended and act as violently as before; for which reason
the pores will not relax, consequently the  pain of resistance will  be re-
newed.    Before the  blistering or stimulating application  can be  made
with prospect of relief, or even without the hazard or risk of injury,  the
following  questions must  be answered in each individual case: Will the
will tell you that the eyes invariably feel the better for it, which is undoubtedly true
hut this effect is only temporary, the disease is no less certainly kept up and aggra-
vated by the practice.  In some cases of chronic ophthalmia, the same effect is pro-
duced by the use of water.  In ophthalmia, cold applications should be applied very ex-
tensively, to the whole head or most of it.  Our principles furnish the explanation. 
COUNTER IRRITATION.
43
irritation of the blister induce the vessels to relax? And if so, has the
action of the heart, or the vis a tergo, been so much subdued that it will
not force the fluids into the diseased vessels, and cause them to be again
over-distended, and therefore prompted again to resist painfully ?   The
stimulating, or " blistering point," is then attained only when the vessels
will relax in consequence of the application, and the vis a tergo so much
abated as not to cause them to be again over-distended.  Prior to this, a
blister will certainly produce the ill consequences to which we have allu-
ded.   In the treatment  of affections of  the joints, the writer has most
frequently noticed this error in practice.  He has witnessed many in-
stances in  which practitioners have applied a  few leeches to a joint, and
followed them with a large blister; the result was what might have been
anticipated by one familiar with the principle—the joint became  swollen,
hot, and painful;  requiring a long succession of fomentations, poultices,
and general treatment, for the removal of the mischief done by the ill-
timed blister.  He has likewise often seen the same bad practice enacted
in pneumonia  and pleurisy—particularly the latter.  The patient  had
been bled, purged, blistered, and, as a matter of course,  made  worse by
the last  remedy, which ought to have  been deferred until  the action of
the heart had been subdued to the degree required.   In all such  cases,
the blister, when too soon applied, may indeed cause the pores internally
to relax; hence the effusion which sometimes (in truth not very unfre-
quently) follows the application of a large blister to the chest in pleurisy,
to the abdomen in peritonitis, or to a joint in synovitis, before the inflam-
mation has been sufficiently subdued by bleeding, etc.*  The vessels, it
is true,  have  been emptied and the inflammation cured by  the effusion;
but another disease, as dropsy of the  chest, abdomen or joint, is pro-
duced—quite an  undesirable result.  Effusion is likewise  very apt to
follow the application of a blister in phrenitis, and many a child has lost
its life in consequence.   After effusion, blistering, by promoting absorp-
tion, may be exceedingly proper and useful.
   In one other respect this class of remedies deserves consideration.  In-
flammation in the incipient or forming stage is often removed at once by
the fortunate application of a local stimulus ; we  say fortunate, because
the  principle  on which it acts under such circumstances has not  been
very clearly pointed out  or  very  well understood.  The vessels directly
  * I have recently seen a case of pleurisy in which a large quantity of serum was
effused  into the cavity of the thorax immediately on the drawing of an extensive
blister on the side directly over the seat of the pain. 
44
INFLAMMATION.
involved are crowded  and over-distended with blood, while those imme-
diately surrounding retain their natural condition, or rather assume the
attitude of resistance, which prevents the over-distended vessels from
forcing  their contents onward,  and in consequence returning  to their
normal  state.   If now a strong stimulant is applied which makes a more
vigorous impression externally than is made internally by the fluids con-
tained in the aforesaid vessels—they will relax and give the fluids in the
first a more easy passage through them and a more ready admission into
the last, by which the ordinary circulation in  the  part  is restored.   In
this way inflammation of the conjunctiva is cured at  once by stimulating
collyria; of the tonsils and  throat by stimulating gargles; and gonor-
rhea by stimulating injections.   But how often do we see matters made
worse by blunders perpetrated  by those who  do not fully comprehend
the principle upon which success is founded.  The general state of the
patient, that of the circulation and of the heart's action, and the duration
of  the  difficulty,  should be   investigated  before  resorting to such
measures.

                            LOTIONS,  ETC.

   Formerly it was the custom to apply medicated lotions, but, with few
exceptions, they are no better  than simple water, except so far as they
amuse the patient or friends.  Under such circumstances they will proba-
bly do  the more good and for  this  reason it may be well to  use them.
Infusions of hops, cicuta, stramonium or  mallows, as fomentations, are
comforting and useful.   Besides  their sedative and narcotic qualities
they make a pleasant impression which causes the capillaries  and pores
to  relax—thus easing pain by taking off resistance.
   Poultices of bread and milk,  or medicated with linseed or narcotics, are
also beneficial.  In a great  majority of cases, however, they may be dis-
pensed with and  cloths moistened with water, or  some of the infusions
just mentioned, laid on the part and covered with oiled silk, used in their
stead.  A sponge, imbued with those liquids and applied in the same
manner, will be found convenient, especially  if it  be desirable to make
gentle  pressure,  the  sponge being  applied and bound with a bandage
 and moistened afterwards.

                               POSITION.

   In conclusion—a word respecting position.  This is a matter which is
 certainly too much neglected.   Gravity, by retarding the flow of blood
 into  an inflamed  part, lessens the vis a tergo,  the impulse and its effect; 
POSITION.
45
moreover, by facilitating the egress of fluids, it diminishes their distend-
ing force which keeps the capillaries on the stretch and prompts them to
make painful resistance.   Position  is thus made to answer all the pur-
poses of an evacuant without the debilitating effects of depletion.  Let
it be remembered that emptying the vessels of the inflamed part is all
that is required for the cure of inflammation, consequently position, when
fully consulted, greatly abates  the demand  and sometimes supersedes
the necessity for active depletion,  therefore the inflamed part should be
elevated as much as is consistent  with the comfort of the patient.  So
thoroughly convinced is the writer of the importance of position that he
treats no case of inflammation, surgical or medical, without reference to it.

   P.  S.—In another point of view, posture is important, and in some re-
spects corroborative of the views presented and  entertained in these
papers.
   Early in his  professional  career the writer was called to amputate the
limb of a  patient so much debilitated that none  of the  gentlemen in
consultation would advise to the operation, from the conviction that the
patient  would die in  its performance—without it,  all agreed that
death was inevitable.  After much reflection and mature deliberation he
arrived at the conclusion,  that, such was  the weakness  of the  heart,
if the limb was raised for a short time, nearly all the blood it contained
would gravitate into the body, which would  then actually contain more
of the vital fluid for the support of functions essential to life than be-
fore ; and furthermore that the effect might be enhanced,  if needed, by
the elevation of other members.   Not that  "rashness triumphed over
caution," but confidence in  the principle prevailed,  and  prompted  to the
operation.  The limb was elevated to a perpendicular,  and sustained in
that posture until bloodless and nearly pulseless, when the  torniquet was
tightened and  the operation commenced and finished.   The other limbs
were also somewhat raised  and kept elevated for several days.  The re-
covery was slow, but fortunate for both patient and surgeon, whose first
amputation it was.  Since then he has not unfrequently, in similar cases,
resorted to the same expedient and always with satisfaction.
   In  extreme  cases, all the limbs  may be raised even  to  a right angle
with  the body, and  sustained in that position for a longer or a  shorter
time, or until they are emptied of their blood, which may be retained in
the trunk for present and temporary use, by compressing  the arteries.
So far as the writer knows, this practice originated with him, at the time
above specified.  Every obstetrician will  readily appreciate its value and 
46
INFLAMMATION.
importance in dangerous floodings—conjoined with opium in large doses,
which  produces relaxation in the  cerebral capillaries, it may  be  in-
strumental in  saving many valuable lives by contributing  to  supply
with blood the nervous centres whose functions  may thus be kept  up
until the system has time to rally. 
INFLAMMATION-ITS  CONSEQUENCES.
In the preceding pages the writer has explained the modus operandi of the
exciting causes in the production of inflammation, and shown that the prox-
imate cause consisted in a decreased action of the capillaries pertaining to
the inflamed part, and that the proximate effect was by inevitable conse-
quence a distended, or over-distended condition of those  vessels, and
that that over-distended condition actually constituted and comprised
the disease itself.  From these premises it was inferred that depletion of
the capillaries,  by whatever agency accomplished, comprised the cure.
Upon that broad inference, the first, second and third indications of cure
were based ;  but as depletion of the aforesaid vessels is not unfrequent-
ly effected or accompanied by a simultaneous effusion of their  contents
into the tissues immediately  surrounding them, or other contingencies
and  consequences which  derange structure or function, another and
distinct indication, not having relation to the cure  of the disease, was
deemed necessary, which we now proceed to consider.

                       Fourth  Indication
   Is to obviate the consequences  of the disease ; or more particularly,
to remove from the part affected whatever has been effused or  secreted,
by which the vessels  have been  relieved and the  inflammation cured.
In other words, the sequels of the disease.
   The reason of this indication is quite obvious ; if the matters  so extra-
vasated were allowed to remain, they would in most instances, as sug-
gested, either impair, interrupt, or destroy the function or structure of
the organ or  part.  If the organ was  essential to life, the most serious
results might be apprehended.  This view of the subject  brings us to
the consideration of the various terminations, technically  so called, of
inflammation.  The doctrine inculcated in these papers is, that inflam-
mation has but one legitimate termination, i. e., by depletion; but as
systematic writers teach, and the profession in general reckon on several,
as resolution, suppuration, ulceration, and gangrene or mortification, we
feel bound to consider them, with the exception of  gangrene, separate-
ly, and in so doing shall endeavor to trace out the  principles on which
they depend, and the laws by which they are  governed, and  also the
 rules by which the treatment proper to each should be regulated.
                               4 
48
INFLAMMATION.
                             Resolution.
   When from the nature of the cause, degree, duration or treatment of
 the disease, the effusion of serum, or lymph, or both,* takes place early,
 or in a quantity so small as to be speedily absorbed, yet sufficient to
 empty the vessels, the inflammation is said  to terminate in  resolution,
 the result always to be aimed at. The signs which evince that resolution
 is taking place, or is about to do so, are to be found in the modifications
 of the phenomena essential  to the existence of the disease ;t viz. in-
 creased heat, redness, pain and swelling. When examining with a view to
 the probable occurrence of resolution, we should pay particular atten-
 tion to the changes manifested in the edges and purlieus of the disease ;
 for instance, the decrease of the redness and swelling is first perceptible
 in or about  the margin of the inflamed part,  before the slightest change
 in either  of these symptoms  can be perceived in other portions.   The
 peripheral parts  being in juxtaposition with those that are in a state of
 health, it is reasonable to suppose, that the vessels of the former will
 first resume the functions of health,  and that the fluids which give rise
 to the abnormal  color  and swelling, will  be absorbed  and removed by
 vessels in the neighborhood, whose functions are only disturbed, but not
 actually interrupted,  as they  are  in other parts where the  morbid
 causes have acted with more energy.
   From the abatement of the  pain, and  subsiding of the swelling, it
 might be inferred that resolution was certainly going to take place ; but
 sometimes the tumefaction does really increase,  and that considerably,
 when resolution is about to follow ;  hence,  if ignorant of the anomaly
 and unacquainted with its cause, we might be led to give a wrong prog-
 nosis. To avoid such a mistake, it is necessary to discriminate between
 the increase of tumefaction by effusion,  and that which arises  from
 mere distention  of vessels,  which is done by noticing  the difference of
 feel;  that  from  effusion is much softer than that from  distention of
 vessels.  The changes  of sensation,  which accompany these different
 conditions, should also be taken into the account as constitutino- an
 important ground of distinction.  When the increase of swelling  is
 from  effusion, the pain, heat and sense of vascular distention  abate, be-

  * The nature of the effusion, though varied by the cause, intensity and duration
 of the  disease, is also modified by the structure of the part. If the disease is slight,
or of short duration, there may be aii effusron of serum only,  causing oedema  or
 local dropsy ; if of a higher grade, or of no longer continuance, coagulable lymph, as
well as serum, will  be effused, and the  part for a time remain indurated, and its
 function impaired.
  t This principle will be likewise observed when considering the other terminations
of inflammations. 
ADHESION.
49
cause the vessels are depleted; when from over-distention, these sensa-
tions are all aggravated, and furthermore, the redness is also increased.
In  fact, the abatement of the aforementioned symptoms affords the
most certain criterion by which to judge of the probability that resolu-
tion will be effected, especially in the early stages of the disease.
  Resolution, in the strictest sense, is accomplished by early restoring
the equilibrium between the capillaries and the pores,* in order to pre-
vent copious effusion.  The means for accomplishing this  having been
considered in former papers, the  rule of practice for the fulfilment
of the fourth indication in connection with resolution, is to promote the
absorption of the  effused  matter, which  is  accomplished by friction,
blistering, compression, made by bandages, compressed sponges, and such
other means  as the ingenuity of  the practitioner may suggest.  The
compressed sponge bound firmly on the part,  and then kept  quite wet
for twelve  or  twenty-four hours often works wonders.  The  oftener it
is exchanged  for a piece that is freshly pressed the better. The general
remedies are  mercury, emetics and cathartics, which  however are sel-
dom required or employed.

                              Adhesion.

  Adhesion is considered a termination of inflammation—erroneously,
as we conceive and have endeavored to show.
  It happens when coagulable lymph in small  quantity only is effused.
Now, the effusion has emptied the vessels and  cured the inflammation;
the adhesion,  being subsequent, is effected by a process entirely new.—
This must be  so; few accidents more certainly prevent adhesion than in-
flammation.   Every surgeon, desirous of securing union by the first in-
tention, anxiously deprecates its approach, which he knows is so apt to
frustrate his  purpose.f   Effusion of fibrine is all that is required in the
first instance ; and  increased action, just enough to produce it, is neces-
sary—all beyond that is to be avoided.   This process of adhesion pre-
sents a series  of interesting phenomena, and  is to surgery what steam

  * It should be kept in mind, that it is not at all times the absolute over-distention
which disturbs the equilibrium, but often  the suddenness and  violence with which
the  contained fluid is forced against the sphincter, if the organ be large, or pore if
a capillary is concerned, which causes them to resist.  Even when vessels are over-
distended, if we make warm, soothing applications, which diminish or take off their
forcible action, the pores will, as has been suggested, relax, and effusion follow, in
which case resolution  may ensue.  In the early stage  only is this to be expected
with much confidence.
  t " Adhesive  inflammation," a most unfortunate phrase, was introduced by John
Hunter, and from his time to the present has misled the profession. 
50
INFLAMMATION.
power is to mechanics—the  origin of invaluable improvements ; the
cause of astonishing results.  It was  first noticed by quacks, who of
course kept the  discovery a secret, and availed themselves of its  ad-
vantages in practice, for the purpose  of filling their purses.   Openly
they dressed and doctored the instrument which inflicted  the wound,*
the lips of which cheatingly they brought  together,  and covered them
with some magic powder or balsam, which kept them in contact.  Charms
and all sorts of fooleries were resorted to for amusing and diverting the
multitude ; but  the healing of the wound in a few days  by adhesion,
was the valuable result.
   The just treatment of all wounds, whether  the result of  accident or
of  surgical operation, requires that the practitioner should have  a pre-
cise and perfect knowledge of the laws by which the process  of  adhe-
sion is governed, and the rules by which the  practice should  be regu-
lated.  The laws are:
   1. The quantity of fibrine effused must be so small as not to prevent
the vessels, new or old, which shoot into it, from inosculating one with
another.}   If they so inosculate, adhesion is perfected by the organiza-
tion of  the fibrine,  and  the morbid process  terminates;—but  if the
quantity effused  is so great as to prevent the  inosculation of those ves-
sels, they will immediately commence secreting pus, and the granulative
process is soon instituted.  The rule of  practice  is,  therefore, to keep
down morbid action, and so prevent the  too copious  effusion of fibrine
and serum, which would prevent inosculation.
   This law, with some slight modification, probably obtains in most in-
ternal inflammations which involve the  serous  membranes.
   2. The surfaces should not be pressed so firmly or closely  together
as to  prevent  the effusion of fibrine—if  so,  they will  act  upon each
other, as extraneous bodies, and excite  inflammation, by which adhesion

  * The practice above alluded to, was not wholly abandoned, even some years af-
ter the writer commenced business; for he distinctly recollects one case to which he
was called, and found that the doctor in attendance had actually applied his dress-
ings to the axe,  the implement which had  inflicted the wound; and another in
which both tines of a pitchfork had been wrapped up, because, forsooth, it could not
be ascertained to a certainty which had inflicted the injury.
  t This law, and  the  rule of practice,  relates to wounds and abscesses • for  if
the sides of a wound or an abscess be not brought so closely in contact that the ves-
sels which shoot from the opposing surfaces into the coagulable lymph (which glues
them together) cannot inosculate or unite immediaiely with one another  thev  will
secrete pus, and form granulations, by which the wound or abscess will be filled, and
ultimately healed.  This species of union, in technical language, is termed " Union
by the second intention." 
USES  OF  ADHESION.
51
will  be prevented.   The rule of  practice deducible from this law is :
To lay and keep the surfaces of a wound or abscess in easy contact by
the gentlest means.
  3. That nothing be interposed which  would prevent the inosculation
of vessels.   The rule of practice is, to remove all  extraneous bodies-
blood, and even fibrine, if the quantity be such as to prevent inoscula-
tion.  This  implies that  all  haemorrhage shall  have been  effectually
stopped, as  well as the blood  removed, before the parts are  brought
into  contact.  Without this precaution,  the blood  subsequently effused
would cause a violation of this very law.*  Although this may be con.
sidered as a modification of the first law, yet we have been induced to
lay it down as a distinct law, in special reference to the treatment of
wounds, and more particularly in relation to an accident which  not very
unfrequently occurs in the practice of the young surgeon ;  to wit, the
turning in of the  edges of the skin.   When this is allowed, union by
the first intention cannot take place;  the interposed cuticle acts as an
extraneous body, and prevents adhesion  as effectually as a piece of wood
or any other foreign substance ;—indeed, the healing process does not
commence until the cuticle is detached and removed, when the surfaces
made raw by the removal will adhere or granulate.  This oversight gene-
rally retards the healing of a wound three or four weeks ; a delay much
to be regretted, without adverting to the pain and suffering so unneces-
sarily inflicted on the unfortunate patient. A good constitution, although
not essential, renders success in procuring adhesion more certain.
                         Uses of Adhesion.
  This process of adhesion, as connected with disease, is of invaluable
utility in the economy of the system.   In the serous membranes within
the abdomen or thorax,  if the  inflammation be  mild,  serum only is
effused—if  one grade higher, coagulable lymph will  be poured out at
the point where the disease is most intense, which will glue the mem-
branes together, and thus stop the further progress of  the malady,
while the effusion around it has emptied the vessels and cured the dis-
ease.  The tendency in these membranes to adhere, depends  upon the
fact that only a moderate degree of inflammation stops the natural se-
cretion on their free surface, and renders it dry.   Now this  dry  sur-

  * After the dressing of a wound, serum, and indeed fibrine, may be effused into
its cavity in such quantity (especially if retained) as to preveut inosculation.  This
retention is caused by dressing too closely, in the first instance; and, iu the second,
by jhe drying and caking of the dressings, which prevents escape of further effusions
Hence the propriety of the cold water dressing,  which not only restrains haemorrhage,
but by  preventing tho drying and caking, facilitates the egress of the serum, &c «
                                     5 
52
INFLAMMATION.
 face, in either membrane, coming in contact with an opposing portion,
 acts as an irritant—as an extraneous body—exciting inflammation in it,
 which in like manner suspends in that spot the ordinary effusion of se-
 rum.   These opposite  surfaces,  thus conditioned, act and react upon
 each other, until coagulable lymph is effused, which glues them toge-
 ther, and serves as a bond  of union, which, becoming  vascularized,  is
 rendered permanent  by the organization, more or less perfect, which
 ensues.   But for this adhesion, the disease would probably have ex-
 tended over the whole  membrane, and in most instances destroyed the
 patient,—by its intensity or extent interrupting the functions of important
 organs; or by the effusion of serum in  such quantities as to produce
 the same consequences in another way.   In cases of this description,
 the rule of practice deduced from the pathology connected with them
 ls, to  moderate or keep the inflammation within certain bounds ; for if
 the quantity of fibrine  poured out be so great as to prevent the inoscu-
 lation of vessels, as heretofore represented, pus will be secreted in such
 quantity as to break up and dissolve the adhesions which surround it on
 every side, and fill the thorax or other cavity with sero-purulent matter.
 In intussusception, the intussuscepted portion of intestine inflames, mor-
 tifies, sloughs off, and is  finally discharged per anum, and the patient
 sometimes recovers—the adhesion having secured the continuity of the
 intestinal canal.  In strangulated  hernia, also, when  the gut mortifies,
 adhesion, fixing the part at  the groin, prevents the escape of  the faeces
 into the cavity of the abdomen, and at the same time establishes an ar-
 tificial anus.   When suppuration occurs in the cellular membrane, ad-
 hesion prevents the migration of the matter from one part to another.

                   Disadvantages of Adhesion.
   Instances  not unfrequently occur  in which adhesion interrupts the
 function of organs, so as to destroy life, or render it exceedingly uncom-
 fortable.
                            Suppuration.
  Suppuration  has been usually considered one of the terminations of
 inflammation; but the intermediate links between inflammation and sup-
 puration seem to have been  overlooked, viz.: the effusion of coagulable
 lymph, and the formation of new vessels, which, with a single  excep-

  * That exception, (if, indeed, it be an exception,) is to be found in the inflamma-
 tion of the mucous membranes.   It is said, and perhaps generally believed, that the
 vessels which open on the surface of these membranes, and which, in a state of
 health secrete mucus, pour out pus  when inflamed.   When inflammation  is
not sufficiently  intense to prevent the  secretion  of  mucus, the quantity  will
 le increased, in consequence of the increased determination  of blood to the mu-
 cous follicles, on the principle that the function of every organ, whether of sensa- 
SUPPURATION.
53
tion,* always precede the secretion of  pus.   These new vessels, which
secrete  the pus, with the parenchyma which connects them together,
compose the  granulations, which, being piled one upon another, fill the
 tion, secretion or motion, is increased by an augmented flow of blood—within certain
 limits—to that organ.   When inflamed, the capillaries which circulate the serum,
 fibrine, or the colorless constituents of the blood, are distended, but empty themselves
 by pouring out fibrine, iuto which the new vessels shoot, which  new vessels,  or old
 ones invested with lymph, as the case may be, as in  other instances,  secrete pus,
 which, mingling with the mucus, has given  rise to  the opinion  that the same ves-
 sels which secrete the mucus secrete pus also when inflamed.   This increased secre-
 tion of mucus is undoubtedly salutary:—1. By depleting the vessels, which tends to
 cure the inflammation.  2. By keeping the inflamed surfaces asunder;—thus obvi-
 ating adhesion and closure of the canals.*  3.  By causing the removalof the lymph,
 or preventing its becoming so fully organized  as to enable it to maintain its ground.
 The motion of these parts  also  greatly contributes to prevent  adhesion.
   We remarked that if the effusion of coagulable lymph was so large in quantity
 as to prevent the new, or primitive vessels, which shoot into it from inosculating with
 one another,  they immediately   commence secreting  pus, which  is deemed  to  be
 " altered blood ;" and that the alteration of the blood, so as  to  constitute it pus, is
 the function  of the new vessels,  but they answer a secondary  purpose, viz. the
 organization of the  lymph ;—their  peculiar,  appropriate  and primary function  is,
 we repeat,  the secretion of pus.  All that is required is an investment  of fibrine
 about new vessels, or the old ones elongated, in order to enable them to perform this
 function.  When the effusion takes place in passages communicating with the ex-
 ternal air, as  in the bowels, urethra, or air passages, it will be readily understood
 why the quantity of fibrine is too small to give rise to granulations, adhesions, or se-
 rious obstructions.   These consequences, it is believed, never happen unless fibrine
 has been effused into the cellular substance immediately surrounding  the mucous
 membrane, and into its texture, by which its peculiar structure  has become
 changed, and its inner surfaces, thus  altered,  are  brought into  contact with  each
 other, and adhering, finally become organized, and the canal permanently closed.
 If ulceration has ensued, the contraction of the granulations, by drawing the  parts
 together, contributes to the same result.   If this union does not  take place, a stric-
 ture may ensue: this, however, depends much upon the size or calibre of the  tube,
 and its destitution of motion, as in the lachrymal ducts, the fallopian tubes and
 urethra.
   In bronchitis and pneumonia, we often hail the secretion  of  pus as a favorable
symptom.   " Like the bow in the heavens," it indicates " the  subsidency of the
storm," because it continues the process of emptying the vessels, begun by the ef-
fusion  of lymph.
   In the  formation  of pus on the mucous surfaces, without the  effusion of lymph,
in such quantities as to  give rise to adhesion,  granulation, or change of structure,
we behold the foresight  and wisdom of  the Creator.  If adhesions formed, death

  * When the inflammation is intense, there will be no secretion of mucus, which we have
 xnlained on the principle that over-distension, and consequently violent action, disturb the
■equilibrium between the excretory vessel and its pore. 
54
INFLAMMATION.
cavity, and constitute what is technically called  " Union, or healing, by
the second  intention."   Although  we sometimes speak of " laudable
pus," the formation of matter is never the product of healthy action.—
It may be modified by the part affected—the state of the constitution—
the cause and character of the disease.

               Symptoms and  Signs of Suppuration.

   Besides seriously involving the reputation of the surgeon, it is, in a
practical point of view, often an affair of great importance to  the pa-
tient to determine concerning the  existence of pus, which is most  cer-
tainly and scientifically done by carefully studying the modifications and
changes that take place in the  phenomena of inflammation, which im-
mediately  precede,  accompany and follow the formation of  matter.
We are, therefore, in every case in  which that result is anticipated, to
keep  a steady eye on those changes.  In the first of these papers, the
phenomena in  question were carefully considered, not merely in strict
regard to the nature of  the disease, but indirectly with reference to this
point.
                               1. Pain.

   In what way is the pain^or sensations [in the part modified, so as to
indicate the formation or existence of matter ?
   In acute inflammation, the ^first  or  earliest symptom indicative of
the formation of matter, or that it is about to form, is the accession of
sharp, lancinating,  shooting, darting pains,  as if needles were  stream-
ing off in various  directions in the inflamed part.*  The change of
action, the  perception  of which"gives  rise  to these sensations, is  the
yielding or relaxation  of thejiores, and consequent effusion of serum
would be the inevitable consequence ; if granulations, they would alter the structure,
and render the part incapable of performing its appropriate function ; or they (the
granulations) might continue to accumulate and obstruct the passages, and in that
way interfere with, disturb, or wholly interrupt the performance of the function.  Our
conclusion is, that the mucous membranes do not afford an exception as hinted in
the text.
  * These sensations are peculiar~to the serous  membranes: the cellular mem-
brane, partaking of their nature, also experiences them. They are somewhat analo-
gous to those which belong to the nerves, but are dihtinguished by the circumstance
that the latter, the nervous pains, dart or shoot-  along the course of the nerves,
while those under consideration move in every direction, and are  connected  with
inflammation. 
INCREASED HEAT---REDNESS.               55
and lymph in such quantities, as to separate parts, cause tissues to give
way, and prevent  the  inosculation of  vessels, new or primitive, which
may shoot into, or be formed in the effused fibrine, whose first function,
if they do not inosculate, is to secrete  pus.   At or about the same
time when these sensations are experienced, the pulsatile, or throbbing
pains,  become more severe,f  which arises  from the increased  resist-
ance of the  capillaries immediately  preceding the  relaxation  of the
pores;  soon  after which the throbbing may be expected to abate, for
the effusion of lymph and serum depletes the vessels.  Taken in con-
nection with  other coexistent  symptoms and circumstances, this abate-
ment is a sign of suppuration.  When suppuration has  actually taken
place,  the sharp shooting pains, and the  throbbing, are in a greater or
less degree exchanged for a  dull, heavy sensation, and often by a sense
of weight, especially if the quantity of matter is large.   As the matter
accumulates, a sense of distention, caused by its pressure, is  perceived,
and  is more especially appreciable on the side nearest the surface. The
patient, if particularly interrogated concerning  his feelings, in respect
to these points, will inform you that there is not only a sense of  weight
as has  been  mentioned, but  also a sensation as if  there was  something
pressing from within outward, and distending the parts, as if endeavor-
ing to escape.
                        2.  Increased Heat.

   When matter has formed, the sense  of  heat, of which the  patient
complained, actually diminishes ; but whether there is really any lower-
ing of temperature ascertainable by the thermometer, I am unable to
say ;  but I have often observed, that it feels less hot  to  the  hand than
before.  When suppuration  is considerable, the patient will occasionally
experience a sense of coldness, as well as of weight in the  part, but
may not mention either, unless his attention is called to them.

                             3 Redness.

   The color of a part being  dependent on the  fluids  which it or its
vessels contain, explains, or  tends to explain, why the increased redness
  t This throbbing or pulsatile feel may, to a certain extent, depend on increased
intensity of the heart's action just at that point of time, and is evidence of the con-
test between the  vis a tergo aud the resistance of the capillaries, or  their pores.
When the  former (the vis a tergo, or action of the heart) abates, the latter will
forego their resistance, and the serum and lymph be poured out. 
56
INFLAMMATION.
 (one of the phenomena of inflammation,) begins and continues to fade as
 the suppurative process advances.   It first verges  towards a scarlet;
 then  beeomes more  diffusive, and  gradually  paler and  paler as the
 matter approaches the surface, until the skin directly over the  immedi-
 ate seat of the abscess assumes a dingy white, contrasting well  with the
 surrounding red.*  If the increased redness is a symptom of inflamma-
 tion ;—if the secretion of pus, or perhaps,  more  properly speaking, the
 effusion of serum and coagulable lymph empties the vessels and cures
 that disease, it cannot fail that, on the occurrence of suppuration, there
 should necessarily be some  modification of that symptom.
   When the process  of ulceration commences  immediately after  the
 formation  of  matter,  the  change of color is not so apparent.   Instead
 of changing to a scarlet, it becomes crimson.   Again, when matter has
 formed and the color in  a marked degree become paler, it has resumed
 the crimson as soon as  the ulcerative process began.   Crimson is
 indeed the color of ulceration.  The change from a deep to a paler red
 is owing to an effusion of serum into the  cellular texture of the parts
 between the surface and the contents of the abscess.  The change to a
 crimson, when the ulcerative process has  been set up and is going on,
 arises from the absorption of serum, leaving  the vessels turgid  with
 blood, which, from its  delay in these vessels, has assumed somewhat
 the venous character.

                         4. Tumefaction.

  When inflammation is progressing the tumefaction also  increases; but
when suppuration  commences, the  swelling commonly  begins to  sub-
side.   While as a whole it has  lessened, some  portion of the inflamed
part may appear, and often is actually more protuberant or "pointed."
  The swelling may be  likewise modified in respect to its hardness or
softness as well as uniformity.  The centre or focus, where  the inflam-
mation has been most  intense, and where the pus is in greatest quantity,
is soft compared with  the margin which is hard and firm in consequence
of the effusion  and  organization of the coagulable lymph, which has
  * For want of due attention, this change of color has been mistaken for asign that
resolution is about to take place—a fact which furnishes a caveat to the young sur-
geon  not to  make up his mind and come to a conclusion, even in trivial matters
connected with professional affairs and  pursuits, without taking all the attendant
circumstances into the account.  To be mistaken, in regard to the existence of
matter, seriously compromises the professional character of even an old practitioner. 
RIGOR OR CHILL.
57
served as a barrier to confine  the matter.  The organization of this
barrier converts it into a cyst, whose inner surface continues to secrete
pus, which is thus  confined to  the cavity into which  it was at first
secreted.   Beyond this cyst and barrier, on every  side  where the in-
flammation  was less, serum is effused and sometimes  perhaps albu-
men ;—the same thing also happens between the cyst and the external
surface ; hence the oedema and pitting not only all around the collection,
but absolutely between the matter and the skin, and not unfrequently
in the latter.  We  have sometimes  found this oedema so great as to
obscure the sense of fluctuation, even when the quantity of matter has
been considerable.   When all the other symptoms are in keeping, this
oedema is one of the surest signs of the existence of matter; it depends
on the very necessity of the case:—for if lymph is effused in sufficient
quantity to be followed as we have shown by the secretion of pus, the
effusion of serum, upon which the oedema depends, will be still more
copious and extensive.
   The foregoing constitute the modifications of the phenomena, and com-
prise the local symptoms which  indicate  the existence of matter; but
there are changes involving more or less the whole  system, which are
also symptomatic of suppuration, with which the practitioner should be
familiar; because matter sometimes forms  in  situations or under cir-
cumstances which preclude the possibility of making the fore-mentioned
criteria of its existence available ;—we are then obliged to resort to other
phenomena as evidences of its existence, amongst which is

                        The Rigor or Chill,

Which, time out of mind, has been noticed in this connection; but the
true nature of which has not been, to the  knowledge of the writer, very
satisfactorily explained,  or its connection with the thing signified, very
clearly traced out.
   In order to understand this matter fully, it should  be recollected that
the cutaneous capillaries are the only vessels  designed by nature to be
ordinarily subjected, to any great extent, or in any considerable degree,
to the influence of temperature, and are therefore the  only ones which
do experience and take cognizance of changes induced by its vicissi-
tudes   The application of  cold, or rather the  abstraction of  caloric,
produces a contraction of the capillaries of the skin, and indeed some-
times of other parts, so much as sensibly  to diminish the size of a limb.
The perception  of change produced by this contraction of the capillaries,
especially of the skin, constitutes the sensation of coldness,—a certain 
58
INFLAMMATION.
sign that that particular action is going on,  no matter how induced ;—
shrinking of the cutaneous capillaries being all that is  requisite to pro-
duce that sensation, or the chill.   Now then, how is the shrinking occa.
sioned, which is indicative of the existence of pus ?   As soon as matter
is formed, a portion of it is absorbed, and passes into the general circu-
lation:—coming thus in contact with  the  inner surfaces of the capil-
laries, which are rendered pre tern aturally sensitive by the prevalence
of the  phlogistic diathesis, it (the matter) makes on them a strange
and novel impression, and stimulates those vessels to contract, partially,
perhaps  at first,  if  the quantity  of matter absorbed  is small—in
which  case a mere chilliness is felt;  but  soon as the  quantity is suffi-
cient to produce a general shrinking, a complete rigor* is experienced,
which  resembles the  cold fit of an ague,  and is not  unfrequently fol-
lowed, as in that disease, by the hot and sweating stages.—Hence the
flashes of heat and colliquative sweats in  hectic fever.   If, as suggested,
the quantity  of matter is small, a slight  chilliness or chill may be pro-
duced—if it is allowed to remain and increase,  the shivering will  be
repeated from time to time,  with  an intensity proportioned to  the aug.
mented  quantity of matter, until a  full rigor is experienced.    When
repeated again  and  again, the  chill  is  a  sure sign,  other symptoms
being in accordance, not only that matter is already formed, but that a
portion  has been absorbed and carried into the general circulation, and
like imperfectly assimilated chyle makes a strange, novel  and disagree-
able impression on the inner surfaces of the capillaries, causing them to
  * The stomach,  rectum, uterus  and bladder may be considered as capillaries of
enlarged dimensions, whose  actions, commensurate with  their size, are easily and
readily comprehended, and therefore well adapted to illustrate the manner In which
that order of vessels perform their function.  All are familiar with the fact, that the
expulsatory efforts of these organs, if abnormal in a slight  degree only, are attended
with a sense of chilliness,  especially in sensitive  persons, which goes off as soon as
their contents are expelled.  In some instances it ceases when the sphincter relaxes
and the evacuation commences, and always when the  organs forego their con-
tractile effort, whether emptied or not.   The same thing may be observed in people
of weak and irritable  temperament, whose digestive  and assimilative powers are
imperfect.  The patient,  in such  cases, not  unfrequently experiences a sense of
chilliness almost as soon as the food is received into the stomach, but oftener after
the lapse of an hour or two,  when it is a sure  proof that the processes of digestion
and assimilation have been incomplete ;—that imperfectly formed chyle, taken up by
the lacteals, has found its  way into the general circulation and is making a strange,
novel and disagreeable impression on the inside of the capillaries which causes them
to contract—hence the sense of chilliness. 
FLUCTUATION.
59
contract; hence the chill  or rigor, which is so often  repeated  when
there are large abscesses or continued ulcerations in important organs.*

                              Fluctuation.

   The  most  unequivocal sign of the existence of matter is fluctuation,
which  should ever be  taken in connection  with  other  symptoms or
changes indicative of suppuration ;  for surgeons, who have relied on it
exclusively,  have found themselves  now and  then mistaken,  and  their
reputation  injured.   In malignant  affections  of the joints and  other
parts, and encephaloid tumors, we are particularly liable to be deceived,
because the sensation communicated to the fingers is so exactly like that
felt when matter actually exists, that it is not only difficult, but next to
impossible, to discriminate  between them  without  taking into the ac-
count the history of the complaint, and  all the attendant circumstances.
To ascertain by  fluctuation,!  the  existence  of matter  when deeply
situated, or under muscles and fasciae, as in the neck,  thigh, or perineum,
often requires  a good share of the tactus eruditus, which experience
alone can give.   The manner of feeling for matter is by  no means un-
important.   Some surgeons  employ  two fingers of the same hand, placed
upon the abscess a little distance apart, when a slight tap is made with
  t After injuries of the head these chills and shiverings are  " portents dire":—they
are almost the only  signs by which we judge of the existence of pus within the
cranium, requiring the trephine—the only agent by which the unfortunate patient
can be saved, if indeed he can  be then saved at all.  In connection with inflamma-
tory affections of other internal organs and deep-seated parts, they are of the highest
importance.  In such cases they should always be most  seriously taken into the
account when  making up our diagnosis and prognosis, without forgetting that the
chill is sometimes caused by simple irritation.
  * Undulation is sometimes mistaken for fluctuation.  In the encephaloid tumor
or disease, the former  is the movement which is  so deceptive.   For example, the
mass, pressed by one hand, is moved by that pressure in the opposite  direction, and
seems to strike against the other with an undulatory motion, which is often mistaken
for fluctuation ;t whereas, in fluctuation, the fluid so  pressed, not only impinges
against the hand, but  can be felt passing or sliding as it were along beneath it.

  t A similar undulatory movement of a very deceptive character  is often perceived, when
an attempt to feel for matter in a limb, is made in a transverse  direction, the muscles and
tissues being pushed from  side to side, cause the sense of fluctuation, which is so apt to de-
ceive the surgeon who remains  satisfied with  this  mode  of examination. To  correct
any misapprehension, the  trial should be likewise made  in the longitudinal direction; if
fluctuation is then discovered, the case is clear. 
60
INFLAMMATION.
one,* while the fluctuation is felt by the other, and vice versa, until all
parts of the impostume are examined. Others employ the fingers of both
hands in the same manner.   The  writer's method is to lay the fingers,
or the whole hand, (supposing the collection extensive or deep under
fascia or muscles,) as the case may  be,  upon the skin, and  press so
firmly as to force the matter away from  under it,  and then apply  the
other hand or fingers to another part, and  press so as to force the
matter back under the hand first applied, which being gently eased up,
will not only /eel the impulse of the matter, but perceive  it passing
along under it.
   If the examination be made by the alternate depression and elevation
of the hands, thus relatively situated, there will  be felt not  only the
sense of  fluctuation, but the sensation of something  moving or sliding
back  and forth beneath the  fingers of  either hand;  generally this
movement  of the matter will be more sensibly and  satisfactorily  per-
ceived by one hand than the other.
   In more doubtful cases, when settling this important question of the
existence or non-existence of matter, we should take  into consideration
the duration and severity of the disease ; for one greatly dislikes to be
mistaken.   The effusion of coagulable lymph, the indispensable pre-
requisite to  the secretion of pus, necessarily requires  some time, before
it can be accomplished in such quantity as  to prevent the inosculation
of the new vessels, by which the pus is secreted ; therefore, the length
of time required for matter to form, will be greatly influenced by  the
structure of  the part affected.   In inflammations of ordinary character
and degree,  when  confined  to  the  cellular membrane and in healthy
subjects, these preliminary changes will be  completed in from thirty to
fifty or sixty hours, provided they have not been much interfered with
by the surgeon or his remedies, so that in the  course of the third day
the secretion of  pus may be expected to have commenced, and proba-
bly to have made a decided progress, and in one  or two days more the
impostume may be fit for the knife.t  There is,  however, so much varia-
tion in regard to time, that it will not be safe  to  place much depend-
ence on  it;  but in doubtful cases it is proper  to consider it.

  * Percussion furnishes a  very delicate, and the exploring 'needle a very certain
test; but they are not  available in every  case.  In  relation to the latter, I
would say that the surgeon  should have recourse to steel  as rarely as possible for
solving doubtful questions.
  t Suppurations on the head, or in the mouth, particularly in connection with
the gums, take place very early, often in twenty-four  or thirty-six hours.  A fig,
roasted or unroasted, taken into the mouth, and applied to the part, acts as a poul-
tice, and is the best remedy that can be employed in such  cases. 
MODIFICATION OF MATTER.
61
  We are often inquired of whether this or that inflammation will suppu-
rate ? Now, if the shooting, darting pains have been decidedly felt, other
circumstances being in accordance, we may reply that such will be the
probable result.   It will be most prudent, however, to give a guarded
prognosis.   When the lymphatic glands in the neck  or axilla inflame,
especially in children,  and the disease has advanced so as to discolor the
skin, we may be pretty sure that suppuration will ensue; but before
the skin is involved, we may hope to discuss the tumor.
  Summarily:—The changes in the sensations, color, tumefaction and
temperature of the part; the chills, shiverings, rigors, flushings, and
other phenomena, together with sensible fluctuations, comprise the evi-
dence on which we  rely for determining the existence of matter.

                     Modification  of Matter.

  Having glanced  at the  importance of attending to symptoms, as
modified by the structure of the part affected, we will now briefly con-
sider the modifications of matter from the same cause.  When pus is
the result of  inflammation in  the  cellular texture, it is yellow, rather
inclining to  white; about the consistence of  cream, not transparent;
without  acrimony,  and when cold,  inodorous.  When secreted  from
mucous membranes, it is seldom  pure ; being mixed with mucus, it
has a greenish yellow, as in catarrh, gonorrhoea, &c.  When muscles
are  involved, it is more  yellow.   In the serous membranes,  it is
blended  with  serum, and  constitutes  the  sero-purulent  fluid,  with
flocculi  of  coagulable lymph  floating  in it.  If the inflammation in
them has been  high, we find large  flakes, or even cakes of fibrine, as
well as  small flocculi;  if  still more intense, the effused fluid  has
more or less  the appearance of blood, which denotes that the  vis a
tergo has not only been violent, but unsubdued; occasionally all these
varieties may be observed in the pleura, pericardium, peritoneum, and
even the pia-mater.  If the suppuration has been in a bone, or a bone
has been involved,  the matter is fetid, grayish, sometimes  containing
globules of oil, and gives a dark stain to the dressings or a probe.   Al-
though the abscess may have formed on and laid the bone bare,  even
to a considerable  extent, yet if the matter is thick, ropy and of a whitish
green or yellow  color, and free from particles of oil or blood, I am al-
ways inclined to give a favorable prognostic in  relation to the preserva-
tion and integrity of the bone itself.
  The pus formed in the liver is almost unique in appearance, reddish,
thick, and not unfrequently mixed with streaks of pure yellow, which I 
62
INFLAMMATION.
have supposed to be  bile.   Even  when  expectorated,  after having
found its way by ulceration, into the bronchia, and  traversed the lung,
it retains this appearance: Moreover it is sometimes so horribly offensive
as to fill the whole house with its odor, so much so that I have more
than once  formed an opinion of the nature of the case the moment I
entered the door.*
   The degree as well as location of the inflammation  may be inferred
from the properties and  appearance of the  matter ; for instance, if it
has been violent the matter may be sanious or even  bloody;—if much
below  the  ordinary degree, as in scrofula, it will be thin, somewhat
like serum  or whey : thus the appearance of matter may be turned to
good account when making up a diagnosis or prognosis.

                          Uses of Pus.

   In the production of pus we have a fluid whose office is to keep the
granulations  moist,  and by  its evaporation prevent their inflaming.
It is nature's cerate.  Besides floating  bodies  out of wounds and ab-
scesses, its secretion may possibly  tend further to empty the vessels
and finish the process commenced by the effusion of fibrine and serum.
   For some remarks on the treatment of abscesses, see Appendix.

                         Of Ulceration.

   According to the doctrines set forth in these papers, neither mortifi-
cations, scirrhus nor even ulceration, is to be considered  a termination
of inflammation.
   Nor is ulceration a necessary  accompaniment or sequel of suppura-
tion ; but a process set up de novo, after the inflammation (when connected
with  that  disease)  is cured by effusion or otherwise.   It sometimes
occurs without previous inflammation, and sometimes quite independent
of it.   It is the work of the absorbents,  and  appears to be induced by
causes which modify or interfere  with the nutrition of the part.
   To be absorbed, solids must become fluids.  We are not aware that
any solid part of the body becomes a fluid during  life without  having
  * This horribly offensive smell likewise attends gangrene of the lungs—the history
of the case will always lead to a correct diagnosis.  Notwithstanding the extreme
danger, the patient in both instances, according to my observation, generally recov-
ers. When the abscess forms in or near the upper part of the liver, and the matter
ulcerates through  the  diaphragm  and lungs, it seldom has this offensive odor.   Its
course and channel through the lungs may sometimes be quite accurately traced by
the help of the stethoscope. 
ULCERATION.
63
lost a portion of the  vital affinity by which its constituent molecules
are held together, and enabled to resist the play of chemical  affinities.
In most instances,  parts when they  become useless, are taken up by
absorption without being apparently  subjected to chemical action.
   The interdict, "ye shall not eat if ye will not work," covers the whole
man: hence every  fibre  or tissue  which  ceases to be useful in the
economy, ceases to be duly nourished, and is consequently  absorbed
without ulceration; that being  unnecessary to accomplish the  object
—the removal of the  useless part.
   Pressure or mechanical distention  of some kind or other is the most
generally  exciting  cause of ulceration.   This pressure  may be of two
kinds.    1. A greatly distended state of the capillaries of the part by
the  fluids which they  contain.*   2. A mechanical  distention which
operates on the tissues in common, and on a considerable portion of their
capillary vessels.   From these two kinds of pressure arise two varieties
of ulceration :   1. When both exert an influence, as in inflammation and
suppuration.   2.  When either  alone acts.  In the  first  variety, the
nutritive process is interrupted by the general distention  produced by
the  effused fluids  and the  absorbents are also stimulated,  by  the
same  cause,  to increased action,  while the capillaries  are  likewise
so much over-distended  and   stretched  as to  experience  a  dimi-
nution of the resistance afforded by the vital affinity which might have
enabled them to have resisted longer, and perhaps with ultimate success,
had it not been for the  general distention and pressure, which not only
increases their ordinary tension, but forces them out of their natural di-
rection—contingencies which, in all their bearings, tend to weaken the
nutritive  process.  As  an  example in point,  I would  mention an
abscess in which  the  matter  presses  from within  outward  on  the
capillaries  most  distended  by their  own contents, and  also by the
matter  pressing  and urging its  way  to  the  surface, which forces
the  fore-mentioned  capillaries to  yield  to the  combined  agency
of these two causes.  In this condition  of things, absorption  goes on
with energy in different parts—internally nearest the matter, and also
 at the surface, t
  * Ulceration in the skin and mucous membranes—surfaces communicating with
the external air, is generally  caused by this species of pressure.  Perhaps in strict
technical language,  the term ulceration should be confined to the lesions it occa-
sions  in those tissues.
  tThis last circumstance most frequently occurs in scrofulous abscesses, in which
several openings are made by ulceration, through which the matter escapes. 
64
INFLAMMATION.
   In the second  variety, the  capillaries being merely over-distended,
 (the general distention absent,) lose  their vital affinity and give way.
 This variety most frequently  occurs in constitutions vitiated  by a ca-
 chectic condition of the fluids, as in scurvy ; in newly formed parts as
 granulations,  etc.—in  limbs  long affected  with varicose  veins, vari-
 cose ulcers, etc.; in such cases the destructive is more rapid than the re-
 parative process—indeed the march of  destruction is sometimes fright-
 ful.  I have seen  more mischief from  ulceration in forty-eight hours
 than could be repaired  in several months, by the restorative powers of
 nature, aided by the most skilful surgery.  Ulceration is generally pre-
 ceded  by inflammation  and suppuration, but not always, as  in some
 cases of tumors,  aneurisms, etc.   Some  textures, more rapidly than
 others, take on  the  ulcerative process,  as  the  skin and mucous  mem-
 branes.  In the latter it is, I believe, invariably produced by inflamma-
 tion.
   The most remarkable feature in the process  of ulceration is its ten-
 dency  to advance most rapidly on the side nearest the surface.   On the
 proximal side, the tendency is reversed.   The structures on that side,
 instead of becoming thinner and thinner, increase in thickness and den-
 sity.   This may be  explained upon the principle that the vital powers
 are stronger on the proximal than on the distal side, and that pressure, if
 slight,  will produce a thickening  of  the part  experiencing  it; but if
 strong enough  to  make a forcible and  disagreeable impression, it will
 impair nutrition, promote and  often cause absorption; and  if  to  such
 pressure inflammation be superadded,  ulceration  will be the certain
 result.   Pressure, either general on all the textures of a part, as from
 matter within an abscess, or from the over-distention of the capillaries,
 is  the  most common, if  not the only  cause of  ulceration, especially of
 that connected with inflammation.   Irritation also has been regarded a
 cause ;  for irritation produces a determination  of fluids to the part in
 which  it is  seated, and  induces a distended state of its vessels, which,
 if  much weakened, are unable to resist the distending force, and there-
fore give way—ulcerate.   Debility may be very justly considered as
 the predisposing cause.
   What is the final end  of ulceration ?   Strictly speaking, it is to rid
the system of useless or offending matter, whose presence  eannot  be
tolerated, but which cannot be taken up by the absorbents and elimi-
nated through some of the emunctories'—as pus, extraneous bodies, ex-
tra vasated fluids, in considerable quantites, and even parts  which have
become useless,  although these are commonly removed by the absor-
bents without ulceration.  The detachment of ligatures from an artery, 
APPENDIX.
65
or of dead from living parts, as in sloughing, could not be effected but
by the process of ulceration.
   In practice, it is important to remember, that some tissues and struc-
tures resist  the ulcerative process much more stoutly than others, as
tendons, aponeuroses, etc., for obvious  reasons.  Allied to ulceration is
gangrene or mortification, which occurs when the disease (inflammation)
is so intense that the capillaries, in some portion of the inflamed part,
become so much distended, or over-distended, and  act so vehemently
that the pores  will not relax, and consequently effusion either not take
place at all, or only in a quantity too small  to empty and relieve
the  vessels,  which  from  over-distention and painful  resistance lose
their vitality; in other words, they resist until they die, which consti-
tutes the gangrene, in which inflammation is said sometimes to termi-
nate, the consideration of which we shall omit.
                            APPENDIX.

                       TREATMENT OF  ABSCESS.

   When an abscess has formed, thetrule  of  practice is, in general, to
 imitate nature, and let the matter out.  She  does this by ulceration—
 the surgeon does it  by incision or puncture.   If the abscess is large,
 and somewhat chronic, its cavity, when emptied  of the  matter, should
 be filled to a moderate degree of distention with  a solution of corrosive
 sublimate,  ten or twelve grains to  the pint, thrown in with  a syringe,
 and allowed to remain a longer  or shorter time, according to the un-
 easiness or pain it occasions, when  it should  be gently squeezed out,
 and the sides of the cavity be brought as nicely  in contact as possible,
 and kept  so by well-fitted and applied compresses and bandages, and
 the whole  kept wet with water, cold or tepid, as is most congenial to
 the feelings of  the patient.  In  this  way the writer  has  cured
 many  abscesses in a few days, and  occasionally those  of an acute
 character in a  single day—the  whole interior surfaces laid and kept
 in contact, have adhered and healed by the first  intention, without an-
other drop of  matter being  discharged.*   No  case  has  come  to his
knowledge in which unpleasant consequences have resulted from this
  * The tincture of iodine is an excellent substitute for the bi-chloride of mercury.
I have seen it used in  the N. Y. Hospital, by Dr. Buck, for the cure of suppurated
buboes, with very happy results. 
66
INFLAMMATION.
 method of treatment.   Often, indeed, many abscesses may be speedily
 healed when thus treated, which if managed in the common way would
 have taken months to cure, or perhaps have cost the patient his life.
   It was formerly supposed that the  admission of air into the cavity of an
 abscess was the cause of the inflammation which so often came on about
 the third day after the evacuation of its contents; this opinion is now pretty
 much abandoned; but no very satisfactory explanation of the fact has
 been given.  The writer ventures  to give the  following:  By the with-
 drawal of the matter the  vessels of the cyst, and those  about  it, re-
 lieved of the pressure which it caused, are soon filled and  over-distend-
 ed with blood, to a degree which stops the secretion.  This process re-
 quires  about  three days, for the  effusion of lymph and  the secretion
 of pus, after which the abscess continues to discharge good  or ill-con-
 ditioned matter for a longer or shorter time.   Now, by using the injec-
 tion as proposed, we anticipate nature's process, and produce a new in-
 flammation and effusion of  coagulable lymph, by which  the surfaces
 are  glued together, and in which new or  primitive vessels, shooting
 from side to side, inosculate and cause the abscess to heal like a wound,
 by the first intention; thus the secondary inflammation,*  to  which we
 have alluded, and which so often comes on a few days after the evacu-
 ation of collections of matter, is prevented, and the patient saved from
 all the hazard and suffering incident to such  an occurrence.
  In chronic abscesses, in which the secretion is vitiated  and the con-
 stitution  cachectic,  the injection of the solution of the corrosive subli-
 mate is the most important remedy, especially when associated with
 the internal use of cantharides, either in tincture or substance—gradu-
 ally  increased  so as to produce strangury—the only sign  by  which we
 know that the system has been brought under its influence, just as mer-
 cury is known to have affected the constitution, when its specific effects
 are manifested in the  gums.  The strangury thus induced is immedi-
ately removed by the single introduction of a catheter; or less promptly
by  the  spirits  of camphor in  sweetened  milk, frequently  repeated.
The  use of the medicine should be suspended—and resumed when the
strangury has left, taking  care to begin with  a diminished dose, i. e.
somewhat less than that by which the specific effect was produced.
  * When the abscess is large the inflammation is dangerous from  the extent of
inflamed surface, and the secretion which follows is almost always of a highly viti-
atic character, especially if the constitution is bad or much weakened. 
3.