[No. 136. [April S, 1826.]

LECTURESON THE

THEORY AND PRACTICE OF PHYSIC,

BY DR. CLUTTERBUCK.

Theatre, General Dispensary, Aldersgate-street.

LECTURE XXI.Gentlemen,HAVING treated pretty fully of blood-

letting as a remedy for inflammation, we are now to consider Counter-irritation, which, in the largest sense of the term,embraces most of the means we are ac-cnstomed to employ, and upon whose

efficacy any reliance can be placed.—There is no subject better deserving yonrattention ; and the more so, as you willfind it difficult to acquire the necessaryinformation from books with regard to it.

Counter- irritation then consists in mak- I

ing a powerful impression on some part of the system, either mind or body, with the view of producing a change in thestate of the living actions, (including ofcourse those of the diseased part or organ)and in the hope, that the diseased partmay afterward resume a healthy mannerof acting : and this is, in fact, so oftenthe result, as to fully justify the meansemployed, though these means in them-selves, may be productive of much tem-porary inconvenience, and even violentdisturbance in the system.

Counter-irritation may be either mentalor bodily; that is to say, the impressionmay be first made on the mind, as themedium of influencing the bodily actions,(as by exciting the passions or emotions ofmind) or directly upon the body itself, byagents foreign to it, which are both verynarious in themselves, and may be appliedto various parts, with greater or less ad-vantage, according to circumstances tobe explained. Again, the impressionmay be either made upon the diseased

part itself, or upon some other part, ac-cording as the treatment is intended tobe local or general. It is the latter, thatwe are at present to consider.

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With respect to employing the mind asthe medium of impression, in order to in-fluence disease, there is ample proof ofthe power of this to accomplish the pur-pose. Mental emotion is capable both ofpreventing, and of curing disease. Strongmental emotion of almost any kind, pre-vents the operation of cold in producingits usual ill effects ; and it is probablethat it tends to obviate many other oc-casional causes of disease, though it maylikewise, at times, favour their action ;as with respect to some contagions is be-lieved to be the case. Terror has on va-

rions occasions cured epilepsy, as well asexcited it; and a fit of the gout has oftenbeen suspended or removed by the samecause, as from an alarm of fire. Themilder passion of hope has been observedto have a beneficial influence on somechronic affections, such as sea-scurvy.Notwithstanding, however, that the in-fluence of mental emotions on disease isnot to be questioned, it is seldom thatwe can lave recourse to them as reme-dial agents, from the difficulty there is inregulating their effect. We cannot, soto speak, adjust the dose, so as to renderthem at once safe and effectual. Cases,however, will not unfrequently occur, inwhich they may be resorted to with ad-vantage, but which it is difficult here toparticularize.

Impression, for the purpose of counter-irritation, may be made on different partsof the body, determinable in some mea-sure by the seat of the disease, as well asother circumstances. There is hardly anypart indeed that is not capable of in-

fluencing more or less, by its condition,the rest of the system. Some parts are,however, preferable to others for thepurpose, either as being more susceptibleof impression in themselves, or as beingwithin reach, or from more readily ex-tending their influence over the rest ofthe system. I should enumerate the fol-

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lowing as, upon the whole, the best adapt.ed to the purpose :-1, the general san-gniferous system ; 2, the stomach ; 3, theintestinal canal; and, lastly, the skin.These all detrmnd further notice, as theyare not equally eligible under all circinn-stances, but reqait selection in their use.The whole sanguiferous system may be

acted upon by general stimulants, so as

at times to influence heneficially manycases of inflammation. For this purpose,the essential oils, spices, camphor, am-monia, snake-root, and most other of theclass of stimulants, and also the differentpreparations of antimony, have all longbeen in extensive use. In the course ofoperation of these medicines, where thesurface of the body is kept warm, sweat-ing is apt to take place ; and hence theyhave been denominated sudorifics, as ifthis was their chief or sole effect, whilethe cure of the disease was generallyascribed to their carrying something iiox-ions out of the system. Now this notioncan not fairly be considered an unrea-

sonable one, in respect to the time inwhich it was first adopted; seeing thatinflammation, in so many instances, ter-minates spontaneously by sweating, whichwas therefore looked upon as the naturalcure of the disease. It is not necessaryhowever for us to adopt this notion, noris it consistent indeed with the presentstate of physiological knowledge. The

practice itself, nevertheless, may often beresorted to with advantage, though by nomeans indiscriminately.The exhibition of general stimulants is

not adapted to the most acute form of in-flammation, especially as taking place instrong subjects, and in the first stage ofthe disease. In such cases, they wouldbe likely to aggravate rather than to re-lieve. But in different circumstances, asin slight affections, occurring in subjectsnaturally weak, or who have been ren-dered so by the previous treatment ; andalso in the more advanced stagesof inflam-mation ; general stimulants, under thename of sudorifics, are often serviceable.As a general principle it may be stated,I think, as pretty near the truth, that aslong as bloodletting is called for, theseremedies are hardly admi&sible; while inalmost all cases, they are rendered bothmore safe and effectual, by previous lossof blood. What I have now said appliesequally to idiopathic fever, and other in-flammations. Fevers, in fact, have beenmore generally treated by sudorifics, thanby any other means ; as yon may see on

referring to the writings of Sydenham, aswell as a host of other writers both he-fore and after his tune. In chronic n-flammations of parts that are naturally I

torpid, such as the lymphatic glands andligamentous structures, stimulants, andthose of an active kind, are unquestion.ably the bet remedies.

I am.inclined to think that the advan.tage derivable from the use of mercury inthe cure of various chronic inflammations,may be explained on a simildr principle,namely, that of producing counter-irrita-tion, hy the change it occasions in thevascular action of the whole system.-There are circumstances also of acute

inflammation, in which it appears to meto be of eminent service; namely, in thelatter stages of the disease, and whenbloodletting has been practised to theproper extent. By thus having recourseto mercury, it is not improbable that amore sparing use of the lancet mightsuffice: this, if true, would doubtless bea great advantage. I have often treatedpneumonia in this way, and satisfactorily;and I am further disposed to think, fromobservation, that mercury is really ser-

viceabie, as has been stated, in the cureof ordinary idiopathic fever. One can

hardly separate the consideration of theaction of mercury on the gums and neigh-bouring parts, from its effects on thesystem at large. It is extremely diffi-cult indeed to produce these effectssingly. In both ways, however, it mayconduce to the general effect.

I before remarked that bloodletting itselfmight be considered as a sort of counter-irritation to the general system, the va-rious actions ot which it so strongly andspeedily influences ; and that its goodeffects were not to be wholly, it’at all, as-cribed to its weakening the system mei ely.Upon this view of the operation of bloodletting, there will be the less difficulty inunderstanding its good effects as a re-

medy for inflammation even in weak siib-

jects, as it often unquestionably provesto be.

The stomach is a part that, on manyoccasions, may be usefully impressed, as

a means of producing counter- irritationfor the cure of inflammation. It is a partof easy access, very susceptible of im-pression by various means, and which

quickly and powerftilly affects by sym-pathy the rest of the system. These aresufficient reasons for the preferenceusually given to this organ, in the appli-cation of remedies,-to say nothing oftheir finding their way by this channelinto the general circulation, an effectthat is probably less frequent than hasbeen supposed.

Medicines may be taken into thestomach, h0 as to produce either nauseaor vomitting, or both, and often with the

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effect of beneficially influencing inflam-mation. The practice indeed has longbeet) in use, and is far from uncommonat present, though the principle uponwhich it acts has not always been suffi-cientfy understood. Dr. Cullen placesgreat reliance upon nausea as a remedyfor fever and inflammation, and whichbe advises to be kept np hy small andrepeated doses of ipecacuanha or anti-

mony. The greatest respect is alwaysdue to the practical suggestions of sucha man as Dr. Cullen, who was seldom

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knistaken in his observation of facts, andalways to be relied upon in his assertions.You will not doubt therefore that the

practice I now allude to, is often a use-ful one, especially in addition to othermean,. Of late the Italian physicianshave recommended large and frequentdoses of tartarized antimony for the cureof inflammation, giving as much as sixor eight grains at once. By this treat-

ment, as they assert, bloodletting may bein a gi-eat measure dispensed with, evenin the iiioit active forms of inflammation.It is difficult to believe, prima facie, thatso powerful a medicine as the tartarizedantimony could he safely administered insuch enormous doses ; and it is my dutyto state to yon, that in numerous trials

purposely made in this Dispensary, I havealmost uniformly tound the operation ofthe medicine to be in proportion to thequantity in which it was administered ;go that I have always found myself com-pelled to desist, when the dose was car-ried as high as three or four grains. In

many instances, repeated doses of a sin-gle grain have produced violent and dis-tressing effects. One would be led to

suspect, that the preparation used wasnot the same in the two cases.

Actual vomiting is of nse in varionscases of inflammation. It has long beenemployed in palmonic inflammation,though in general with a different viewnamely, that of promoting expectoration,which it probably does in some degree.I have seen it of great service in lum-

bago, and some other forms of rhemna-tism. It has been used also in hernia humoralis, when the disease has become

stationary, and after bloodletting hadbeen employed. Of late, it has beeu hadrecourse to in obstinate cases or ophthal-mia, which bieedinn had failed to cure.

Vomiting is a powerful remedy in put-ting a stop to fevers at their commence-

ment, whether of the intermitting or

continued kind ; and it will occasiotaal:ydo tlti, in some even of a specific natate,as scarlatina. A few years ago, whencm’tLcs were more used than at present

in the cure of fever, and when I was lessacquainted with the advantages of blood-letting, I have very frequently witnessedtheir good effects in this way : and if it beso useful in the cases mentioned, it is

easy to believe that the same remedy isapplicable with advantage in many others.It is impossible to ascribe the good e f-fects of vomiting in many of the casesabove allnded to, merely to the evacuationproduced by it, or the discharge of anything noxions from the system; while

they are easily referrible to the principleof counter-irritation. The great changeinduced in the actions of almost everypart of the system, by the states both ofnausea and actual vomitting, are too ob-vious to insist upon, and they appearadequate to the remedial effect observed.

This practice is not altogether free fromobjection in abdominal inflammation,on account of the mechanical violencenecessarily exerted on the contents otthis cavity in the act of vomiting. Wherehernia exists, the practice is also liable toobjection; as it is likewise where a ten-

dency to apoplexy is present. The meansof producin:; vomiting are of no great im-portance. The object being counter-irri-tation, it is obvious that the mildest meansmay not be the most effectual. It is agood general rule, that vomiting, for allthe purposes mentioned, is renderedmore safe, and probably more effectualalso, by previous bloodletting, especiallyin diseases of the brain.

The intestinal canal is situated equallyfavourable with the stomach, for the pur-poses of counter-irritation. It is easy of

access, sufficiently open to impression,and both by its extent, vascularity, andsympathy with other parts, affords a

powerful medium of influencing the restof the system. In acting upon this parttoo, we influence, in a secondary way, anumber of other organs situated in thesame cavity, and connected with it by si-milarity of office.The almost sole object in acting upon

the intestinal canal in the treatment of

diseases, has hither to been that of dis-charging its contents with greater fre-quency than usual, or, as we call it, ofproducing purging; upon the supposition,that something noxious was thus carriedthat something noxious was thus carriedoff, upon the retention of which the dis-ease depended. This notion appears tohave been entertained in all ages, down

to the present time; and accot dingly noclass of remedies has been in such con-

stant use as that of cathartics or purga-tives, especially for the cure of inflam-L maliou. At the present day, the stoola

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are 8crutinized with a degree of minute-ness that is quite ridiculous, not to saydisgusting; and standards have beenestablished for their colour, consistency,quantity, and so forth; as if the wholears medendi were confined to the night-table. Now nine times in ten, the changesobserved in the alvine discharges, are theeffect and not the cause of the disease.They may, no doubt, be usefully attend-ed to, as indications of health, or other-wise ; but in themselves, except in par-ticnlar cases, they throw but little lightnpon the nature of the disease, nor dothey in general suggest the proper modeof treatment. On many occasions, the

changes observed in the state of the eva-cuations are the result of the very meansemployed to produce them; and thusoften lead to improper practice. I mightinstance this in the case of children, inthe healthiest of whom the doses of calo-mel and scammony ordinarily prescribed,will at any time produce the most unna-tural and offensive discharges; the ap-pearance of which again, is thought asufficient reason for a repetition of themedicine ; till at length actual, and oftenirremediable disease, is excited in the in-testinal canal, if not throughout thewhole cavity.My object, Gentlemen, in making thest

remarks, is not to call in question th(

utility of purg-atives on a great number ooccasions, nor to dissuade you from areasonable use of them; but to guarcagainst excess, and especially to point outthe false principles upon which they arEfrequently administered. When youconsider the extent of surface upon whichpurgative:) act, and the many other or-gans that are secondarily influenced bythem; the irritability and vascu!arity olthese parts altogether ; and the greatchange in the batance of circolatiou tlialtakes place under the operation of me-dicines of this description, it is easy tc

understand that they must be a powerfl1medium of influencing the general systemso as to become a source of counter-irritation, independent atike of the quantityor quality of the matters dischargedAnd it is in this point of view chiefly, thaithey are to be regarded as remedies fOJinflammation.

Purgatives appear to be of general usein inflammations of the head, neck, andekin, and that whether acute or ch2-onic.On many occasions they may be trustedto alone, though they ought Mot to beallowed to supersede bloodletting in casesof greater magnitude. Like emetics, theymay be considered as more effectual,when used after bleeding than before.

In most inflammations of the alimentarycanal, and of the abdominal viscera ingeneral, they are of great importance.In enteritis, however, of an acute kind,and attended with absolute constipation,they are capable, if urged far, or of adrastic kind, of doing much harm. Theviolence of the inflammation should besubdued by bleeding, before the moreactive cathartics are employed: and, in-deed, if that object is attained, evacua-tion will in general readily, if not spon-taneously, follow. So that there is in re-ality less need of active purgatives inthese cases, than is commonly supposed.They are objectionable in another reo

spect, by their tendency to excite vomit-ing, one of the most distressing symptomsot enteritis. This objection does not ofcourse apply to the use of purgativesin the way of injection, a practice thatcannot be too much commended.

It has been a general observationamong physicians, that pnrgatives are

less efficacious in thoracic inflammation,than in others. In diarrhœa, or inflam-mation of the mucous surface of the in.testines, the exhibition of a mild cathar-tic, such as rhubarb, is generally properat the commencement of the disease, andin most cases suffices for the cure. Youmust bear in mind, that the often repeateduse of active purgatives, may excite in-flammation in the canal, and in this wayprove injurious. It is especially necessaryto be aware of this in int’ants, and inpatients labouring under fever, or otherbrain-affections, who may be incapable ofdescribing their sensations.The skin is a part which, by its high

state of sensibility, as well as its irrita-

bility and great vascuiarity, is well fittedto be a medium of impression to the restof the system. As an organ of sense, itsaffections readily and powerfully influ-ence the brain, and through this, the restof the system. The skin may be actedupon in various ways, in order to pro’dnce counter-irritation. Heat, cold, anda variety of irritating applications, maybe employed for the purpose, some ofthem with the effect of inducing actualinflammation, which is then to be con-sidered as the remedial agent.

The hot-bath is often serviceable in in-ternal inflammations’, especially of anacnte kind. The practice, however, re-quires limitation, rt is not adapted tothe most active form of inflammation instrong subjects, at least till the violenceof action has been somewhat subdued bybloodletting or other means. The hot-bath is not proper, where the breathingis much oppressed. I have seen it induce

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an alarming sense of suffocation in suchcases, by increasing the general circula-tion at a time, when the lungs are not ina condition to transmit the blood as fastas it is sent to them by the riglit side ofthe heart. The hot-bath is also objec-tionable where the vascular action of thebrain is in a state of great excitementThe semi-cupium, pediluvium, and fo-mentations, are all to he considered aspartial applications of the hot-bath, and admit of the same general observations being made with regard to them.The sudden and intense application of

cold to the skin, as by the cold bath, orcold affusion, produces a great and uni.vei-sat effect on the system, as is evidentby an examination of the different func-tions. It is an agent therefore well cal-culated to influence diseased action

by counter-irritation. It has not, how-ever, been employed to any great extent,from a dread of its use. We are so ac-customed to attribute inflammation to

cold, as its cause, that it is difficult atfir st to consider it in the light of a remedy.We have, however, sufficient proofs of itspower to check the course of ordinaryfever in many instances: and it has beenoccasionally employed in erateritis; not somuch, however, with the intention of di-rectly relieving the inflammation as toovercome the constipation generally present in these cases. But we are in wantof facts npou this subject.

Stimulating the skin in various ways,as by friction, irritating applications, andexciting inflammation artificially, bycaitth(ti-ittes and the like, comes under thehead of counter-irritation. These are tobe reckoned rather among the secondaryor auxiliary means of cure, than as prin-cipals, though they are sometimes suffi-cient for the removal of slight and clll onicinflammations. It, as there is reason tobelieve, it is the inflammation excited byblistering, and not any discharge occa-sioned by it, that is the source of thebenefit derived, one sees no ground forthe preteience so generally given tocantharides for the purpose; for inflam-mation of the skin may be much morequickly produced by the mustard-poul-tice, and also by ammonia in a liquidform, than by the application of blisters;which, by the general irritation theyoften occasion, amounting sometimes todelirium, and still more by the inflam-mation they are so apt to excite in thenrinary paesages, are liable to greatobjection, and often wholly inadmissi-ble. What particular preference is dueto the erysipelatous inflammation excitedby blistering, in comparison with the

pustular inflammation produced by tar-tarised antimony, is far from being sa-tisfactorily ascertained. The counte1’-irritation produced by issues and setons,

is adapted to the chronic, rather thanthe acute forms of inflammation.

t may observe respectitig blisters, thatthey are not well adapted to the earlystage of violent inflammation, while the

general vascular action is in great ex-cess. In such cases, they tend ratherto aggravate than to mitigate the dis-

ease, as well as to disturb in a high de- gree the general system.

SELECTIONSFROM

LECTURES DELIVERED

IN THE

Theatre of the Royal College of Surgeonsin Ireland.

BY MR. COLLES.

On Tetanus.

Gentlemen,ANOTHER consequence of wounds, ia

the disease commonly called tofk-jaw, weshall hereafter examine, whether it oughtto be considered a spasmodic affection ornot. It supervenes to every variety ofwound ; I have seen it occur when thecuticte under the eye was merely raisedby the lash of a whip ; I have also seenit follow amputation, and succeed to acontusion of the leg, over which the wheetof a car had passed. Lacerations, how-ever, and wounds of tendinous parts, aremore likely to produce it than any otherspecies ot injury. I[ is, indeed, impossibleto say, in what case it wiii not occur, andif it should come on after an operation,we should, iu justice to each other, lookon it as an unfortunate accident whichcannot be guarded against. Every periodof life is equally busceptible of this dis-ease ; but there ai three periods afterthe receipt of a wound, when it usuallyappears. The first is when the symp-toms set in immediately after the inflic-tion of the injury, and the patient is de-stroyed in twenty -four hours. If, after