T

ment should fail, then yon may try a weaksolution of the nitrate of silver, putting afew drops into the eye two or three timesa day. In cases of spreading ulcer andgreat irritability, you may employ the so-lution of nitrate of silver, or of the com-

position I before described, the lapis di-vinns. 7he vinum opii is of no service.I can only say, with regard to the greatvariety of stimulants and astringents thathave been recommended, that I havenever seen much good done by them. Thecrusta lactea, which is very tronblesome tothe child, and annoying to the parentsand friends, may in general be greatlybenefited by the use of the oxyd of zinclotion ; a drachm of the oxyd to anounce of water is about the proportion inwhich it is used. The morbid surfaceshould be well cleaned with tepid watertwo or three times in the day, and thewash may then be applied to the part. Asolution of the corrosive sublimate, a

grain to six ounces of water, may be usedas a lotion with advantage. No means ofthis kind should be resorted to, until afterthe use of purgatives, and when thetongue is clean. A sudden repulsion ofthe eruption may aggravate the ophthal-mic inflammation. Children are often

very much disfigured by the. incrustations;but there is one consolation, the scalesnever leave any cicatrices or pits in theskin, and the personal appearance is un-injured even in the worst cases.

LECTURESON THE

THEORY AND PRACTICE OF PHYSIC,

BY DR. CLUTTERBUCK.

Theatre, General Dispensary, Aldersgate-street.

LECTURE XX.

Gentlemen,I HAVE, in this Lecture, to speak

)f Bloodletting, as a remedy for Inflam-mation.

There is no remedy which will bear acomparison with this, in point of efficacy ;and none which, under certain circum-stances, can be so little dispensed with.You are not, however, to Imagine that itis always successful, or always proper.

When used with the greatest judgment,it will sometimes fait ; while there aremany circumstances of inflammation towhich it is not adapted, and in which itmay even prove injurious. It is much tobe wished that we knew the way in whichbloodletting effects its purpose, in the cureof inflammation; for this knowledge, if itcould be obtained, would greatly assist usin the application of it. The subject,however, is difficult, and I am not surethat it is sufficiently understood. Youare not to suppose, as ignorant peopleoften appear to do, that we bleed a patient in order to draw off the bad bloodhe may have in his veins. Nor is theremuch better foundation, I believe, for theopinion, that it is useful in any case, bymerely lessening the quantity of bloodin the system, upon the supposition thatthere is an over-fnlness of the vessels, orwhat is termed plethora. Again, it is notsimply by inducing weakness that theobject is attained ; for then the good ef-fect would be more in proportion to thequantity of blood lost, than is found tobe the case. A small quantity of blooddrawn in a certain way, often producesmuch greater advantage, than a largequantity differently taken. The relief ex-perienced from bloodletting is sometimesso instantaneous, even while the blood isHowing, as not to admit of the supposi-tion that it proceeds merely from theweakness occasioned by it. It seems morereasonable to believe, that the good effectis owing to the impression made on thegeneral system, influencing its mode ofacting ; just as in cases of what are calledcounter- irritation, which I have beforeexplained to you, and with which this

appears in some degree analogous. Ifthis be true, it must be desirable to takeblood in that way which will make the

greatest impression on the system, andat the least possible expense.Now the more rapidly blood is taken

away, the greater is the immediate effectproduced by it; so that a very few ouncesbursting suddenly, as it were, from the

vessels, will affect the system more thantreble the auantitv when slowlv drawn.If it be drawn faster than the blood ves-sels are disposed to contract, so that thesides of the vessels are not brought incontact with the blood, the circulationwill necessarily be at a stand, and syn.cope or fainting enue. Now the bloodvessels contract more readily in some in-dividuals than in others, and such per-sons do not so soon become faint frombleeding. This does not depend alto-

gether npon the general strength, butupon other circumstances. When the

system is in a febrile state of action, faint-

8

ing is not so likely to occur, because thenthe vessels are more disposed to contract.Hence it is, that patients more readilyfaint on the first bleeding (the generalfebrile action not being yet established)than on a repetition of it, although theyhave become actually weaker.The effect of bloodletting may be either

temporary or permanent; depending uponthe rapidity with which the blood is

drawn, and the quantity taken. Thetemporary effect is according to the rapi-dity with which the blood is drawn ; a

very few ounces taken quickly from a

large orifice, especially if the patient bein the erect posture, will produce greatsense of weakness, and perhaps absolutefainting. These effects, however, sooncease; that is, as soon as the vesselshave time to contract themselves, andthe circulation is restored. If the bloodbe taken slowly, and in the recumbent

posttire, so as to avoid fainting, theweakness induced by it is according tothe quantity of blood lost; and the effectis in this case permanent.Now sometimes it is most desirable to

produce a great temporary effect, withoutinducing lasting weakness. In diseasesof great violence, where it is an object tosuspend as quickly as possible the pro-gress of the disease, rapid bloodlettingis to be preferred, and in the erect posi-tion, in order to make a sudden and

powerful impression on the system. Butif the effect is required to be lasting ra-ther than sudden, then it is better to takeaway the blood slowly, and in the recum-bent posture; as it is not otherwise easyto obtain as large a quantity of blood, asmay be necessary for the cure. There isanother reason why it is in general notadvisable to take away blood very ra-

pidly, which is, that the occurrence ofsyncope is both distressing to the patient,and alarming to the by-standers ; and itbecomes more difficult in consequence, torepeat the bleeding as often as the casemay require. It is sometimes proper, inrecent and violent inflammation, to go ontill the pulse flags or is otherwise altered,and till signs of approaching syncopeappear. But this requires to be donewith caution ; for some persons bear theloss of a very large quantity of blood, andsuch as might even prove dangerous, be-fore they become faint.The chief circumstances to be attended

to, as regulating the use of bloodlettingin inflammation, are the following: thedegree and du?-atio2i of the disease ; theage and habit of the patient, in regard tostrength and weakness ; also the state of

the pulse ; the nature of the part affected ;

and, lastly, the nature of the inflammationitself, as being common or specific.The extent to which bloodletting is to

be carried, in respect to quantity and re-petition, is also a point of great impor-tance, and is governed by its effects onthe disease, as being favourable or other-wise ; by the state of the blood drawn,and other circumstances ; all of which itis necessary that I stionid notice, in orderthat yon may be able to apply the remedywith safety, and with the greatest ad-vantage.That the use of bloodletting will be

governed in some measure by the degreeor violence of the disease, must be veryobvious to you. Generally speaking, themore violent the inflammation, the greatercall there is for this, and other activeremedies. But even in slight cases, whenthe disease is seated in important organs,especially those in which there is a ten-

dency to disorganization, bleeding maybe advisable; upon the principle, that" the safest practice is the best," and be-cause the slightest degree of inflamma.tion in such parts is capable, by continu-ance, of injuring the structure. Manyfatal terminations of disease in the lungsmight be prevented by acting upon thismaxim.

The stage of the disease is a poiut ofgreat consequence. In all cases of in-flammation, bloodletting is More effica-cious, the earlier it is resorted to ; so

that it commonly becomes less and lcss

effectual, the longer it is delayed ; tiil atlast it may be wholly inadmissible. This

applies more strongly to the case of properor idiopathic fever, than perhaps any other.At the outset of this disease, bloodlettingis unequivocally, and almost invariably,safe and effectual; while, in an advancedstage of the disease, it requires to be em-ployed, if at all, with great caution.The habit of the patient in regard to

strength and weakness, will doubtlesshave much influence on the use of blood-

letting as a remedy for inflammation,though not in the way and to the extentthat are commonly supposed. There isno difficulty in regard to strong subjects ;but a very unfounded prejudice exists

against bloodletting in weak ones. I canventure to assure you, from much expe-rience, that bleeding is frequently as ne-cessary, and as safe too, in weak as in

strong subjects, when the nature of thecase calls for it; the difference is merely

I in regard to quantity. You are to bearin mind, that the loss of three or fourounces of blood in a weak subject, is equalto a pound in a strong one. With this

precaution you have nothing to fear.

9

Again, neither infancy nor old ae are inthemselves opposed to bloodletting ; ininfants, on the contrary, there is, gene-rally speaking, a greater necessity for it,on account of the greater rapidity withwhich inflammation in such subjects pro-ceeds to disorganization and death. Thereis nothing so mistaken, as the consideringinfancy a state of weakness ; for at thisperiod, all the vital actions are performedwith the greatest energy. Great cantion,however, is necessary in regard to qttan-tity-ounces being neally equivalent to

pounds in adults. In old age, likewise,bleeding is frequently necessary in casesof inflammation, though it does not re-quire to be so promptly administered ;whilst it must be emplo)ed only to a mo-derate extent, I knew an old lady con-siderably more than ninety years of age,who on account of frequent returns ofvertigo, was in the habit of being bledevery six or eight weeks, for some yearsbefore her death.

pulse is not always to be taken as a signof absolute weakness; for, in many in-flammations, the pulse is generally in thisstate ; as in inflammation of the heartmore especially. It is often so likewisein the beginning of other inflammations,when bloodletting is the most useful; andin these cases, the pulse rises, as it istermed, after bleeding, and when the

disease is further advanced. In a greatnumber of cases of inflammation. the

pulse is scarcely altered from the naturalstate, and yet bloodletting may be highlynecessary. We are to take our indica-tions, therefore, more from the other cir-cumstances of the disease, than from thepulse alone, which is very liable to de-ceive us. When, in any case, where thepulse is small and weak, you find uponinquiry that the patient a few days be-fore, was in the possession of a tolerableshare of general strength, and that no

large evacuation, or other cause of weak-ness, has taken place in the interval; youmay conclude that such a state of pulseis merely the effect of the disease, and isno argument against bleeding, if otherwisenecessary. On the other hand, fulnessand even strength of pulse, are not alwaysa sufficient reason for bleeding; as in thecase of acute rheumatism, to which Ishall presently allude.The appearance of the tong°ue is, in most

cases, a very good guide to bloodletting.In almost every case where the tongue ismuch coated, and at the same time dry,

bloodletting may be safely and usefullypractised ; provided due attention is paidto quantity, and the strength of the pa-tient at the time. This state of the tongueis always indicative of active inflamma-tion, such as will very generally bearabstraction of blood, although the quan-tity proper to be taken at once may some-times not exceed two or three ounces.

The advantages derivable from small andrepeated bleeding, appear to me to beneither generally known, nor sufficientlyappreciated ; and, therefore, I wish to

impress you with the subject.The nat1l1’e of the part affected has a

greater influence in regard to bloodlet-

ting than you might at first suppose.This remedy is more prompt and effica-cious in inflammation of some parts, thanof others. It is most useful, perhaps, in

diseases of the chest, and least so in li-

gamentous inflammation, as in rhenmatism. The difference here, indeed, i.

very striking. In the most acute form o’F rheumatism, that which is commonly, termed rheumatic fever, the indicationst’ for bleeding are of the strongest kind.There is more pain, more febrile heat,

You ought to understand well how farthe pulse is to be relied upon as a giiidt,to bloodletting in inflammation, a pointupon which a good deal of error exists.A very frequent pulse in inflammation,

must be taken in conjunction with othercircumstances, in order to jnstify bleed.ing. Such a state of pulse IS more likelyto occur in weak, than in strong subjects;and, therefore, is prohibitory, at least ofbleeding to a large extent. In inflam-mation of the heart, however, the pulseis very frequent, even in strong subjects.A slow pulse generally indicates oppres-sion of the brnin. This oppression maybe owing to recent and active inflamma-tion ot the organ, producing arterial dis-tention, and consequent interrupted cir-culation, in the brain. In this case blood-letting is getierally indispensable. Butthe oppression may likewise be owing toextravasation of blood, or serous accu-

rnulation, the consequence perhaps ofinflammation, though not of the itnlam-mation itself, which may have subsided,the effect only remaining. In these cases,slowness of pulse would be no reason forbloodletting, which could not, in the na-ture of things, be productive of anyimmediate relief.

A strong ptiase generally justifies bleed-ing, where the case is such as to requireit, at least it may be done with safety,though it may not he always advisable.But a weak pulse does not necessarilyprohibit this evacuation, if there shouldbe an urgent call for it in the nature ofthe symptoms. You are to recollect also,what I before stated when speaking ofthe pulse, namely, that a small obscure

10

more strength and fnlness of pulse, anda more inflammatory appearance of theblood, than in any other disease. Yet,experience proves that bleeding, thoughoften useful and even necessary, is farless efficacious than in other inflam-mations ; and, when carried to a greatlength, seems even adverse to the cure. Inlike manner bleeding appears to be moreuseful in inflammation of serous than ofmucous membranes. It is less necessaryalso in the latter, as there is a sort ofnatural cure to these inflammations, name-ly, the increased secretion, and consequentdischarge from the inflamed membrane ;as in cases of catarrh, diarhcea, and thelike. But there is certainly no founda-tion for the notion entertained by some,that inflammation of the mucous mem-brane is of so depressing a nature, in re-gard to the general system, as not to ad-mit of loss of blood : on the contrary, Iyon will often find it necessary in thesecases, when the inflammation is veryviolent or extensive.

The nature of the inflammation itself,as being of a common or specific kind, aswe call it, is always to be taken into ac-connt. In the specific inflammations,bleeding is seldom more than palliative;and it is not often required, even for thispurpose.The extent to which bloodletting is to

be carried, as to quantity and repetition, issubject to great variety; determinableby the state of the disease-the effects ofthe remedy-the state of the blooddrawn-and various other circumstances.It is impossible to lay down an absoluterule with regard to quantity : the ef-fects being so different under differentcircumstances. In persons of tolerablegeneral strength, and at the middleperiods of life, the quantity may varyfrom six or eight ounces, to twenty orthirty, according to the violence and dan-ger of the disease. The quantity should beless, the longer the disease has subsisted.In children, from 2, or 3, to 6 or 8 months,from one to three ounces may be con-sidered as the safe limits. In old sub-

jects, on the other hand, it is seldomproper to take more than eight or tenounces; and this quantity, may be evenconsidered large. Taking these pointsas your guide ; you will easily fill up theoutline, so as to adapt your practice tothe circumstances of the case. In re-

gard to repetition, this is governed chieflyby the continuance of the disease; thusit is often necessary to resort to blood-letting a great number of times-that is,either till the object is accomplished, ortill it appears improper to proceed fur-

ther a point that is to be determinedchiefly by the strength of the patient-and this again, by the state of the pulse.The interval to be allowed between thedifferent bleedings, is governed chieflyby the part affected, and the known dis-

position of the disease, to proceed rapidlyor otherwise. When the small intes-tines, for example, are suffering from

, active inflammation, six hours can hardlybe allowed to elapse, without a recur-rence to bloodletting, if the disease con-tinues ; but in most other inflammations,a longer interval may be allowed.The whole quantity of blood required

to be drawn in any particular case, andwhich can be taken with safety, it isdifficult and hardly possible to assign.In some cases of pneumonia, one hun-dred, a hundred and fifty, or even twohundred ounces have been taken in the

space of a few days ; and less would nothave sufficed for the cure ; but you arealways to consider, what other means youhave in your power, to assist the bleed-ing, so as to make this the less necessary.The appearance of the blood, when

drawn, is an uncertain guide, with re-spect to repetition. The absence of theinflammatory crust, affords no decisiveobjection to further bleeding-nor is thepresence of it a sufficient reason for itsfurther employment. It is by no meansnecessary to bleed, till the inflammatorycharacter disappears from the blood. Itis sufficient, in general, that the symp-toms give way-and even if they shouldnot, as is sometimes the case, we may beobliged from mere weakness to desist:a great disproportion between the crassa-mentum and serum, will in some degreeserve us as a guide. A large quantity ofcrassamentum, may be so far taken as anindication of general strength, as to justifyeven large bleeding, where the circum-stances of the disease appear to demandit ; and, on the other hand, a very smallquantity of crassamentum, floating as itwere in a large portion of serum, shouldmake you cautious in regard to further

bloodletting; at all events, such a stateof the blood, will allow only of a sparingquantity to be taken. You are not to be-lieve, however, with the vulgar, that insuch cases the blood is turned to water-for you will find that the serum, when ex-amined by the proper tests, contains an

ample quantity of albuminous matter.

More attention is paid to the firmnessof the crassamentum, than is requisite. Ingeneral, where this is loose and easilybroken, it is taken as an indication of adegree of weakness that will not beat

11

bloodletting. This, however, is not a ge- neral rule; for in simple idiopathic fever,the blood is always in this state, evenwhere the subject is strong; and yet Iknow from experience, that bleeding insuch cases may be safely and usefullypractised; provided it is done at a properperiod, that is, very early in the disease.

The pulse is to be carefully watched,where it becomes necessary to take bloodrepeatedly, and to a great extent ; for itis by this sign, principally, that we deter-mine the length to which venesection canbe safely carried. The pulse becomessmaller and weaker in proportion as theloss of blood is carried further; and thereis a point beyond which it is not prudentto go. Unfortunately, there are no meansof determining this point with any preci-sion. We cannot measure minute degreesof strength and fulness of pulse, so as tobe able to communicate our sentiments

upon these points to others. This kind ofknowledge must be acquired chiefly fromobservation and experience. In judgingof the general strength, you must nottrust wholly to the pulse, but inquire intoother circumstances indicative of strengthand weakness; such as the feelings of thepatient, his various movements, and eventhe expression of his countenance.

Highly as bloodletting is to be prizedas a remedy for inflammation under avariety of circumstances, it is neverthe-less necessary you should use it with cau-

tion, as knowing that, when misapplied, iit is capable of doing much harm. Oneof the ill effects ascribed to it, however,and which has deterred many from em-

ploying it where it is obviously wanted,is its supposed tendency to induce dropsy,or, as it is often expressed, to occasioneffusion. Thus it is said, if you bleed totoo great an extent in pneumonia, youwill give rise to hydrothorax, or effusionin the chest. But the serous accumula-tion in this case, is the effect of the in-flammation, and not of the bleeding,vhich, by checking the inflammation,tends rather to prevent the effusion, thanto cause it. A large loss of blood is oc-casionally followed by slight osdematousswelling of the feet and ancles, butnever, as far as I have seen, by generaldropsy, nor by effusion into cavities asthe mere effect of the bleeding.

Blood may be drawn in different ways ;as 1st. from some large vein (phlebotomyor venesection) 2. From arteries (arterio-tomy) ; ; 3. By leeches; and, 4. By scari-fication, with or without the aid of ’cup-ping-glasses. These different modes of

drawing blood, are more or less useful,according to circumstances.

Venesection is, upon the whole, greatlypreferable to the others, as being morecertain and determined, easily piactisedin most cases, and decidedly more einca-cious ; as in this way a more sudden andpowerful impression is made upon the

system, and the disease in consequencemore influenced, than by either of theother modes mentioned. Arteriotomy, onthe contrary, is difficult to be executed,with precision and certainty, so as to ob-tain a determined quantity of blood in agiven time. There are few parts whereit can be safely practised, or at least with-out considerable inconvenience; and itoften requires extensive pressure to bemade, in order tu restrain the bleedingafterwards: while, even if it could be sodone as to ensure the obtaining the re-

quisite quantity of blood in a given time,(which is far from being always the case,)it has no peculiar advantages, or bene-

ficial influence over the disease, to com-

pensate for the inconveniences I havementioned.

The application of leeches is of all, theleast efficacious mode of taking blood ; as,from the slow way in which the bloodflows, the impression made either on thegeneral system or on the disease, is notin proportion to the quantity of bloodlost. The body altogether may be greatlyweakened by the successive application ofa great number of leeches, without anybeneficial impression being made on thedisease, as I have repeatedly seen:

while, in these very cases, an almostimmediate stop has been put to the dis-ease afterwards, by the sudden abstrac.tion of a very few ounces of blood from «

vein. It appears to me to be an error to

! suppose, that the system will not bear an;equal loss of blood by venesection, as byleeches ; the effect ultimately, in bothcases being in proportion to the quan-tity of blood lost. When bleeding iscalled for at a time that the system isgreatly weakened, as is sometimes thecase, the blood should be drawn so as

to produce the greatest effect at the leastexpense of blood, and this undoubtedlyis by venesection ; which, however, insuch cases, had better be done so as toavoid actual fainting. Leeches have ano.ther inconvenience, namely, that it isdifficult to estimate the quantity of bloodlost. What I have now said in regard toleeches, applies to the case of children,as much as to adults ; and you will findit much less difficult to bleed children itthe arm or neck,. than is commonly sup-

12

pose-d ; while it is a far more prompt andefficacious mode of giving relief.

The division of the vessels of the in-flamed part by puncture or scarification,is undoubtedly often useful ; but this be-longs rather to the local, than the generaltreatment of inflammation. Scarification1vitlt cupping-glasses, near to the part af-fected, is a useful mode of drawing bloodin many cases, but upon the whole muchinferior to venesection, for the reasons Ihave just stated in regard to leeches.

Cupping, possibly, may have some ad-

vantage, as producing a kind of counterirritation. But in this respect, dry cup-ping, as it is called, would probably havean equally good effect: this remedy (drycupping) is, I think, more neglected inmodern practice than it deserves.

It was formerly supposed, that the

taking blood from one part of the bodyrather than another, was a point of someimportance. The hottest disputes at onetime existed among physicians, as to

whether in cases of plenrisy, the bloodshould be taken from the arm on the sideaffected, or from the opposite one. Andeven at present it is considered, by ourcontinental neighbours, far more ser-

viceable to bleed in the foot in certa’i diseases, than from the arm. I am notprepared to say that there may not besome foundation for this; but the ques-tion is hardly possible to be decided. Inthis conntry, we are in the habit of tak-

ing away blood as near as possible to thepart affected ; but there may be as littleground for this preference as for theother.

I have now explained to yon, as far asI am able, the chief circumstances whichregulate and modify the nse of bloodlet.ting in inflammation ; and, I trust, yonwill see the necessity of using it withcaution. I may repeat, that it is in nocase an absolute or certain remedy ; nordoes it remove the disease in a directway. It only gives to it the dispositionto subside, and that only under certaincircumstances, which you ought, as far aapossible, to make yourselves acquaintedwith.

REVIEW.

A Practical Treatise on the Arterial Sys-tem, intended to illustrate the importanceof studying the Anastomoses, in referenceto the new Operation for Aneurism, andthe Surgical Treatment of Hæmmorhage.By THOMAS TURNER, Member of theRoyal College of Surgeons. 8vo.

pp. 194. Longman and Co., London;Aston, Manchester. 1825.

As aneurisms, arteries, and anastomoses,present, in our day, but scanty mate-rials for an original volume, we think the

present work might have formed a partof the 11 Otitlines of a Medico-ChirurgicalEducation," which the author publishedabout two years ago.* In the first sec-

tion, he describes the structure, func-

tions, and diseases of the arterial system ;in the second, the usual origin and courseof the main arteries of the body, withthe distribution and terminations of their

branches ; and, in his last, the anastomo-

ses of arteries are considered in i-elation

to the common operation for aneurism andthe surgical treatment of hæmor rhage.! With respect to the treatment of aneu-rism, he endeavours to prove-’, 1st. That (with the exception of theaorta, when it is obstructed above the

lumbar branches) if the main vessel be

obliterated, the anastomosing circulationis always sufficient to support the hfeof the part.

2dly. That more is to be feared of too

many anastomosing branches than of

few.

Ontlmes of a System of Medico-

Chirurgical Education, containing illus-trations of the application of Anatomy.Physiology, and other Sciences to theprincipal practical points in Medicine andSurgery. 8vo. 1824.-See THE LANCET,Voi. V. p. 202.