3011. Diseases Of The Abdominal Viscera

Acute Peritonitis, Enteritis, and other Abdominal Inflammations, should, in accordance with modern views, be treated on the general principles laid down when treating of Inflammation. In strong, robust individuals, when the symptoms are urgent, a full blood-letting may be necessary; but, under other circumstances, local depletion by leeches, followed by fomentations, poultices, and the free use of Opium internally, is often sufficient to control the disease and bring it to a favourable termination.

3012. In Acute Inflammatory Dysentery, in the first or inflammatory stage, venAesection has the sanction of Annesley, Twining, Johnson, Martin, Morehead, and our best authorities, both in former and present times. To be serviceable, however, it must be had recourse to early, before ulceration has become established. In young plethoric Europeans whose constitutions are unimpaired by length of residence in tropical countries, or by other causes, especially intemperance, blood-letting may be resorted to not only without fear, but with positive advantage; in others, however, who present a converse state, or whose symptoms present anything of an adynamic form of the disease, or where the symptoms have persisted for several days unchecked, local depletion by leeches over the colon or ccum, or to the verge of the anus, should be substituted. In all cases it must be regarded as an auxiliary to other measures, and not trusted to alone. It is inadmissible in the scorbutic and cachectic forms of the disease, and in the Dysentery of the natives. In severe Ileus, blood-letting has been advised, but it will generally yield to full opiates, with carminatives, warm water enemas, the hot bath, &c. In the passage of Renal or Biliary Calculi, and in some obstinate Spasmodic Affections of the Stomach and Bowels, which resist the employment of Opium and the hot bath, the rapid abstraction of blood sometimes affords immediate relief.

* Lectures, vol. i. p. 840.

Dict. Pract. Med., vol. i

In the passage of Biliary Calculi, however, Dr. Thudichum regards blood-letting as useless.

3013. In Cholera, some practitioners commence with bloodletting, with the view of relieving existing congestions, but the propriety of this measure is very doubtful. A reference to the table showing the ratio of deaths under several lines of treatment (sect. 1414) points out that the percentage under blood-letting, when it has been used in conjunction with Calomel and Opium, is 59 per cent., which, though less than under Calomel and Opium alone, or under that of stimulants, is very high when compared with that of salines, ice, &c. It is said that Broussais, the great advocate for blood-letting, renounced his faith in it in the treatment of Cholera; and most practitioners abandon it, if, upon theoretical grounds, they have been induced to adopt it. Dr. Sutherland observes that the effects of bleeding in Cholera are very uncertain. In Edinburgh, in 1832, a patient was bled and recovered, but in the next 39 cases in which it was employed they all died. In the epidemic of 1848 it was again extensively employed in Edinburgh: out of 12 selected cases 11 recovered, who were bled; and in one gentleman's practice, 4 out of 5 recovered under the abstraction of blood. Dr. Sutherland, however, justly adds that the treatment which is curative one week will often prove useless in the next (Mr. Ross.*)

3014. In Acute Hepatitis, a full blood-letting at the outset is often invaluable in reducing the inflammatory action. The extent to which it should be carried it is difficult to define, as each individual case may require some modifications; but Sir R. Martin supplies us with a good criterion by which we may judge of its having been carried to the required extent, viz., " a sense of local and general relief, with softening of the skin." The indications for blood-letting in Hepatitis are, - 1, An early stage of the disease; 2, a first attack of the disease; 3, a short residence in tropical countries; 4, youth, and a robust plethoric habit of body; 5, a dry open locality, in contradistinction to low, damp, malarious sites, or over-crowded cities; 6, the existence of much constitutional disturbance, accompanied by a hot dry skin, full strong pulse, white dry tongue, and acute pain in the right hypochondrium, whether attended by tumefaction or not; 7, complications with Pleuritis, Pneumonia, or Remittent Fever. The Contra-indications, or Cases in which blood-letting should be used cautiously and sparingly, are - 1, Advanced stages of the disease; 2, long residence in the Tropics; 3, intemperate habits, confirmed drunkenness, or constitutions broken down by previous disease, long courses of Mercury, &c.; 4, Cachexia of any description; 5, a damp, malariously situated locality; 6, a case of relapse; and, 7, any indications of suppuration. Chronic Affections of the Liver are best treated by local depletion: general blood-letting is rarely, if ever, required. Leeches to the verge of the anus are often of the greatest service, by directly unloading the portal venous system.

* Lectures on Cholera, Med. Times, vol. xix. p. 107.