_Of the Suppurating Ulcer._
This genus, like the last, accurately speaking, does not belong to the
class of ulcers; but, as it is so intimately connected with it, both
in its causes, and treatment, and appearances, it is of some practical
utility to admit the arrangement.
When an abscess is opened before the ulcerative action is induced, we
have an open suppurating sore; but this is not the sore which is meant
to be described here.
The suppurating ulcer is, when simple, and independent of any specific
action, most frequently only a high degree of the overacting ulcer;
but, as its symptoms are somewhat different, and as it nearly resembles
some specific sores, differing from these only in the absence of the
peculiar action, resulting from the application of a poison, it may be
proper to consider this as a separate genus.
When the ulcerative action is very imperfectly carried on, which often
arises from overaction, we find, that the organic particles are thrown
out, not in the form of granulations, but in a more inorganic state,
and lie upon the surface, mixed with the discharge from the other set
of vessels. This has the appearance of very thick tough pus, and the
sore which yields it may properly be considered to be in a suppurating
state. This ulcer is distinguished by the pain which attends it, by a
redness which surrounds the margin, and a hardened base, whilst the
cavity of the ulcer is filled up with a thick straw-coloured substance,
somewhat like lymph, which adheres firmly to the surface. This is
improperly called a slough.
This appearance and condition may be excited in a simple ulcer, without
any apparent application of contagion; but it is still more frequently
the consequence of some morbid matter acting on the part, and producing
specific ulceration, which will be afterwards considered. I may only
here observe, that it has, in some of these cases, been considered as
a species of gangrene, as, for instance, in the cynanche maligna; but,
whatever may take place in the advanced stages of this disease, there
is at first no gangrene, but a suppurating ulcer, which throws out
imperfect granulations, or rather a morbid purulent discharge (for the
one runs naturally into the other), which forms what is called a slough.
The treatment of this ulcer consists first in procuring a separation
of the tenacious covering, by such remedies as shall, at the same time
that they do this, make the action more healthy.
A pretty strong solution of the argentum nitratum, or l’eau
mercurielle, diluted with equal parts of distilled water, applied by
means of a brush, frequently produce the desired effect.
The acetous infusion of Cayenne pepper, applied in the same way, is
likewise useful.
Poultices made of decoction of camomile flowers, and equal parts of
charcoal and barley meal, are sometimes of service in removing the
matter, and rendering the action more truly ulcerative.
Opiates ought to be freely administered.
When this state of the sore is removed, the ulcer must be treated
according to the condition of the ulcerative action. Most frequently
it belongs first to the overacting genus, and must be treated
accordingly, and then to the genus of indolent ulcers, in which case,
pressure is to be employed as a termination to the cure.
When an overacting ulcer has, without the assistance of local
applications, ceased to overact, it not unfrequently suppurates; that
is to say, no granulations are formed, but the two sets of vessels
throw out an inorganic matter, and the surface of the sore has a
lymphatic appearance.
The best dressing for this state is dry lint, with a pledget spread
with cerate laid over it.
_Of the Effects of the Ulcerative Action on the Constitution._
The condition and qualities of an ulcer, do not, in every instance,
depend upon causes which are entirely local, but frequently are
connected with some general state, or mode of action, of the system.
General weakness must, for example, influence the performance of any
action in a particular part; and, therefore, an ulcer in those who are
infirm, and exhausted, cannot readily perform the necessary healthy
action, or proceed quickly toward a cure; nor is it easy, in these
circumstances, by any local applications, to communicate the necessary
action, and the correspondent power, which shall enable the part to
heal. In the same way, there are some people so irritable, that an
ulcer shall very readily assume the overacting state, which can only
be removed by such remedies as act on the general system. Besides those
which may be considered as simple conditions, there are many other
actions, which are peculiar and unnatural, which influence the ulcer,
or in which ulcers often appear as symptoms. These ulcers are specific,
and must be afterwards considered.
As the state of the system has a considerable influence on the
condition of an ulcer, so also has the state of the ulcerative action
an effect on the constitution. A healthy ulcer, unless very extensive,
has little effect on the system; but, unhealthy ulcers, or those which
are very large, although the action may be sufficiently perfect,
produce a greater or less degree of the general diseased formative
action, or what is called hectic.
From the principles which have already been laid down, it may easily
be understood how an unhealthy ulcer should induce hectic. When
considering the doctrine of suppuration, the effects of this on the
constitution, or the production of a general diseased formative action
were attended to. It was also mentioned, when considering ulceration,
that the ulcerative action had a tendency to produce similar effects;
and this it does, with a certainty proportioned, cæteris paribus, to
the unhealthy condition of the action, or its approximation to the
suppurative action; for the less perfect that the ulcerative action is,
the more nearly does it resemble the suppurative one.
Healthy ulcers, if very extensive, produce likewise considerable
effects on the constitution. This is chiefly perhaps owing to the
purulent action, which makes a part of the ulcerative one; for this
morbid local secretory action induces a general change, in the same
way as other acute changes, of either the formative action itself,
or any other intimately connected with it, such as the interstitial.
But, besides this cause, the granulating action, although healthy,
co-operates with the diseased interstitial action, or the purulent
part of the ulcerative action; because, although the granulations, or
organic particles, be healthy, yet they are formed in an unnatural
situation, and with greater rapidity, and in greater numbers, in a
given time, than naturally they ought to be; and, therefore, the
action of the part requires greater power for its continuance than is
possessed. There is consequently, then, weakness produced, which, by
association, affects the system, and co-operates with the diseased
formative action, increasing the general disease. The consequence of
this state, likewise, is, that the ulcer comes, after some time, to
be rendered unhealthy, owing to the deficiency of power to support
the necessary action; in which case, the granulating action comes to
be also diseased, and co-operates still more with the former morbid
condition of the interstitial vessels, or the purulent action, which,
although a part of a healthy ulcerative action, is yet itself a morbid
secretion, and an unnatural action.
The effects of the ulcerative action on the constitution, are to be
alleviated by good diet, free air, and the other remedies which have
been pointed out when formerly considering hectic, to which I now
refer. I shall only observe, that some of these remedies are employed
occasionally with little judgment, and when they are not indicated. It
is, for instance, a common practice with some, to prescribe the bark
for the cure of every ulcer, whether the constitution be affected or
not. But, from many trials, I am confident that it is of very little
service, unless when a general disease, whether it be called weakness
or hectic, exists.
When the proper remedies for the cure of hectic, conjoined with
necessary local applications, fail, the diseased part must be removed;
but, before doing so, it is, in every instance, proper to form a pea
issue, in order still to keep up a secretory action, the good effects
of which have been already noticed.
The restlessness, and febrile symptoms, which are sometimes produced by
painful sores, are best relieved by anodynes.
_Of the Cure of the Inflammatio Debilis, and the Treatment of
Mortification._
The causes and nature of mortification having been already explained,
I shall now consider the means of prevention, and the method of cure.
The remedies necessary for procuring the resolution, or suppuration of
the inflammatio valida, having been formerly enumerated, it will be
unnecessary here to make any repetition, or to say more than that we
are to prevent mortification by endeavouring to induce one or other of
the other terminations, and that the remedies which do so are to be
employed with a promptitude and assiduity proportioned to the greatness
of the action compared to the powers of the part; and, therefore, that
in the intestines, &c. we must pursue our course speedily, if we
expect to prevent gangrene.
Mortification, however, is still more apt to succeed the inflammatio
debilis, or inflammation of weakened parts; and, therefore, the
treatment of this will now more naturally come to be considered, as
forming a part of the prophylaxis of mortification, than in any other
place.
The most frequent instance which we have of the inflammatio debilis,
is the inflammation of parts which have been previously benumbed with
cold; but it may also be produced by the action of any of the common
exciting causes of inflammation, in weak and reduced habits, or by
bruises in sound parts, &c.
When a part has been exposed to much cold, it may inflame, from two
causes: First, the communication of action; secondly, the application
of subsequent stimulants, more especially heat. Both of these tend to
excite an action in the part, which is greater than its power would
naturally perform, and, therefore, it becomes diseased, or inflammation
is produced, and the little energy which did remain is soon destroyed.
The operation of the first cause is prevented by lessening the action
of the surrounding parts, by the application of moderate cold, whilst
we avoid motion, and whatever may tend to act directly on the part,
and co-operate with this cause. The operation of the second cause is
prevented by keeping away every agent which will tend to excite action,
or at least those which tend to do so suddenly. In the generality of
cases, it is perhaps most proper at first to do nothing; because,
whatever we apply, tends to excite a greater action than can be
sustained; we ought, therefore, to delay any remedy until the part
has begun to recover itself, and the action and corresponding power
has begun naturally to increase; we may then interfere, by applying
such remedies as increase the action, which are perhaps now more
useful, by preserving the ground which is gained, than by increasing
still farther the action. Of this kind is heat, which must, upon this
principle, be applied with great caution, and must, in its degree, be
nicely adjusted to the existing state of action. When a part, then, is
benumbed with cold, we ought at first to apply a degree of heat, very
little above that which the parts were formerly exposed to, which, in
one sense, may be said to be doing nothing; for this step is intended
merely to prevent farther injury. When this is continued for a short
time, we may suppose that the part has begun to act a little more in
a natural way, which is attended, as was formerly explained[69], with
a correspondent increase of injury. We then increase the heat, but
very slowly, and taking a long time to bring the part near its natural
temperature, being regulated by the progress which the part itself is
making; for the application of heat may be considered in two points of
view, in this case; first, as the removal of the injuring cause; and,
secondly, as a stimulus to action. If, then, the part do not recover
itself, in proportion to the removal of the hurtful cause, but remain
stationary, it is evident that a farther removal is at present useless,
and the stimulus which is consequently given is highly dangerous. By
these means, then, we proceed slowly toward recovery, and keep up the
ground which we have gained.
[69] See the preliminary dissertation.
If, however, the action of the part have been sunk very low, then
recovery is impossible, there being little or no energy, and so little
action, that it cannot increase itself toward the natural state. In
this case, our endeavours must fail, and will even kill the part sooner
than if we had let it alone; for the least increase of action destroys
the life of the part, which may, in this case, be compared to a dying
taper, which gives one brighter flash before it becomes for ever
extinguished.
If, on the other hand, the action have not originally been sunk so low
as to make the process toward death continue progressively, but the
remedies have been applied too quickly, or, from any cause, have failed
to produce this effect, then the action becomes inflammatory. The pain
becomes of a burning kind, there is a feeling of pulsation, and the
part becomes redder, or livid, whereas, before, it was bluish; from the
stagnation of the blood, there was no feeling of pulsation, or arterial
motion, and the sensation was that of a painful cold and weight. The
inflammatio debilis is now induced, and the danger is great, but still
there is a possibility of recovery, which is exactly in proportion to
the degree of previous diminution of action, and to the rapidity with
which the subsequent inflammatory action was induced, and the degree to
which it is raised; or, in other words, the danger is proportioned to
the disparity betwixt the action and the power.
The remedies for this disease are such as tend to induce an action
similar to the natural one, by which we remove the diseased one; for
we know of none which excite the natural action directly, otherwise
they would be of universal utility, and would, in the present instance,
be preferred to every other. The remedies which we employ with this
intention, are bark, opium, &c. internally, and vinous, or spiritous
applications externally. These, however, would be pernicious, were
there no inflammation present, because they would, by exciting action,
tend to induce this; but, when, the inflammatory action is once
induced, then, as they excite one more nearly resembling the natural
one, they are useful; for, on the one hand, they destroy the morbid
one, and, on the other, increase the power of recovery; but, for this
purpose, internal medicines, and good diet, must be given, as a source
whence the energy is to be renewed, by the renewal of the natural
action. Heat is of the most pernicious tendency in this complaint;
because it simply increases the exciting action, and, therefore,
makes the inflammatory action still more violent. The applications,
therefore, ought to be cold, as long as the morbid action continues;
but, when it is abating, and recovery is going forward, they may be
made a little warmer, as they will thus accelerate the healing process
which is taking place; but this requires much prudence.
Spirit of wine is one of the best applications in this disease, and is
one very generally employed. Camphor is frequently added to it, and
appears to increase its efficacy. Pledgets dipped in camphorated spirit
of wine, and applied to the part, will, if frequently renewed, in many
cases, remove the inflammation, and prevent gangrene; but, in every
instance, it at least relieves the pain, which uniformly returns, if,
when the inflammation is violent, we omit the application, or use a
weaker spirit, such as the proof spirit.
Essential oils, particularly that of turpentine, which is easiest
procured, are also useful, but are inferior to the alcohol.
Laudanum, in slight cases, is useful as a topical application; but,
if the inflammation be more severe, it must be mixed with rectified
spirit. A very useful application may be prepared by adding two ounces
of laudanum to a pound of the spt. vin. camph. of the pharmacopœia.
Internally, the bark must be exhibited in full doses, with such a
quantity of wine as the feebleness of the pulse points out; but we
must be prudent in this respect, because, if we give too much, we may
increase the local disease. As long as it does not increase the pain,
or quicken the pulse, it is to be considered as useful.
Opiates are extremely necessary in the inflammatio debilis, and, in
general, require to be given freely.
Soups, and other articles of nourishing diet, are absolutely requisite,
and ought to be given in small quantities at a time, but frequently
repeated.
By these means, we may frequently resolve the inflammation completely;
but, at other times, when we have gained a certain ground, the
inflammation terminates in the suppurative action; or, in other words,
when the parts have gained more strength, and the action has come more
nearly to resemble the inflammatio valida, which has continued for some
time, a similar termination takes place. This event cannot, perhaps,
in these cases, be prevented, and, although it may occasionally
protract the cure, yet it diminishes the danger, making mortification
less to be dreaded. The best treatment, in these cases, perhaps, is
to continue our usual applications, avoiding warm poultices until the
action be fully formed; then moderate heat may accelerate the progress
of the abscess toward the surface. The same internal medicines must be
exhibited, the anodynes, however, being gradually diminished as the
pain (which marks the necessity for their use) abates.
It too frequently, however, happens, that either our remedies fail,
or the proper ones are not assiduously and judiciously employed, in
which case mortification takes place. This requires the same treatment,
in whatever way it is induced, only its progress is, from certain
causes, more rapid[70] in one case than in another, and, therefore,
requires the more free use of the appropriate remedies; but the
general principle is, in every case, the same, and, therefore, I shall
here consider the disease indiscriminately, whether it succeeds the
inflammatio valida, or debilis; because, in both instances, the case
is exactly the same, only, in the first, the weakness which induces
mortification, is produced by the inflammation alone, whereas, in
the second, it existed to a great degree before the inflammation was
excited.
[70] It is more rapid in the inflammatio debilis than in the
inflammatio valida, and in very delicate parts than in parts which are
less so.
Mortification is to be prevented from succeeding the inflammatio
valida, by timely bleeding, and the use of the agentes dissimiles, by
which we procure resolution, or at least make the induction of the
purulent action more easy. In the inflammatio debilis, it is to be
prevented by remedies of an opposite nature.
When, however, these remedies fail, and mortification does take place,
our great object must be to prevent it from extending far, and from
injuring the system. These intentions are answered by the same remedies
which cure the inflammatio debilis; because the local treatment of
mortification is merely that of the inflammatio debilis; for it is
only the parts which are still alive, or inflamed, which can be acted
on by our remedies.
The remedies are either general or topical, and may be considered under
these divisions; but both must be used at the same time.
Many of the older writers, proceeding upon the humoural theories,
began their treatment of gangrene by bleeding and purging, after which
they prescribed theriaca, and other stimulating applications. Some
modern authors still adhere, in part, to this practice, and consider
the loss of blood to be advantageous in cases of incipient gangrene.
Mr. Bell, who is one of the latest writers on this subject, informs
us, that, when the “general symptoms of inflammation, particularly a
quick, full, or hard pulse, still continue violent, and especially
when the patient is young and plethoric, it then becomes absolutely
necessary, even although mortification may have commenced, to empty
the vessels a little by one general blood-letting,” which, “in such
cases, may in reality be considered as an antiseptic; and it does often
indeed, in this particular situation of mortification, prove more
powerfully so, than all the different articles in general enumerated
as such.” If, however, we consider the nature of mortification, and
the circumstances under which it is most likely to occur, we must
look upon this practice as dangerous, and must be permitted to doubt
whether the full hard pulse is to be met with after the commencement of
inflammation, or whether the symptoms of the inflammatio valida, (in
which alone bleeding is admissible) still continue violent, after one
portion of the inflamed part is evidently gangrenous. Is it reasonable
to suppose that one portion of the inflamed part shall be already dead,
or dying, and that yet the rest shall not have begun to suffer? or
that the action shall not have become converted into the inflammatio
debilis, (if it were not originally this)? This surely is not the time
for bleeding, purging, and debilitating remedies; but the part must be
considered as possessing the low inflammatory action, and the patient
as requiring suitable remedies. It may indeed be said by some, in
favour of bleeding, that the bark, in some instances, does not check
the progress of the disease; but it surely does not thence follow, that
it does positive injury, and that remedies of an opposite nature are
useful.
The Peruvian bark is, in many cases, one of the most useful internal
remedies. It was originally introduced into medicine, about one hundred
and fifty years ago, as a cure for intermittent fever; and its utility
in gangrene is said to have been discovered by its curing this disease
in a person who had it combined with ague, and who was taking the bark
on account of the latter complaint. For many years after it was known
in Europe, great prejudices prevailed amongst physicians against its
use, partly on account of its having been improperly administered, but
still more because it was so unfortunate as to cure diseases without
necessarily either sweating or purging the patient, a fact which could
be only ill explained, or rather scarcely allowed to be possible, by
the prevailing theories of physic. Accordingly, although the cases in
which it had been successful were by no means a secret, and although
severals had the courage to employ it, in spite of all speculative
arguments, yet neither Dr. Boerrhave, nor his commentator, Van Swieten,
thought it expedient either to recommend or prescribe it. Renewing the
motion of the stagnating blood by venesection, and the exhibition of
trifling remedies, which could scarcely be called cordial, although
sometimes dignified with that epithet, together with the external
application of ardent spirits, or oil of turpentine, constituted the
current practice in gangrene. These prejudices against the bark, which
originated in ignorance, and were supported by attention to a foolish
theory, continued long; but the want of a better remedy began at last
to make them gradually give way, and the success of empyrics who used
the bark soon completed their downfal.
The bark induces an action nearly similar to the natural one, which is
greatly injured, and, therefore, it gives a check to the progress of
the disease; but, if its operation be not assisted by nourishment, &c.
its good effects soon subside, because the materials whence new energy
can be drawn are withheld, and, therefore, the system cannot profit so
much by the establishment of the new action, and by the restoration
of the power of converting the vital principle of foreign matter into
nervous energy. The bark, then, is of service in two points of view:
First, it changes directly the action of the system, it induces, in
a considerable degree, an action somewhat similar to the natural
action, and, therefore, counteracts the general action of descent
which was taking place. Secondly, by inducing this action, it, to a
certain degree, produces the same effects for a time which would have
been produced by the natural action itself, or increases the power
of renewing vitality; for, in the preliminary dissertation, it was
mentioned, that the production of energy was exactly proportioned to
the perfection and healthiness of the existing action. The good effects
of bark, then, cannot be obtained without nourishment and free air.
It uniformly happens, however, that, in many instances, where the
action of the bark would be most beneficial, it is impossible to induce
it, owing to several causes, but particularly to its effect on the
stomach; for, in many instances, it produces sickness, or nausea, in
which case it can do no good, and ought to be abandoned. Momentary
sickness, after taking a dose of bark, is indeed a very general effect,
and does not materially injure its operation; but, whenever it is
either frequently vomited, or produces a sickness of considerable
duration, it must either be given in smaller quantities, or in a
different form, or at longer intervals; or if all of these fail, it
must be laid aside completely, because it not only cannot produce its
specific effect, but will even injure the remaining powers by its
effect upon the stomach.
The best form in which bark can be prescribed is that of powder, which
is more effectual than any tincture, or the extracts. This ought to
be exhibited in as great quantity as the stomach will bear, which
cannot be reduced to any certain scale. In general, an adult ought, if
possible, to take half a drachm, or two scruples, every forty minutes,
in the most palatable vehicle; for much depends upon the taste, owing
to the sympathy betwixt the mouth and the stomach; and, for this
reason, the same vehicle ought seldom to be used more than twice in
immediate succession; because, by changing the vehicle, we not only
change the taste, which has a tendency to prevent loathing, but also
modify the immediate action on the stomach, changing, to a certain
degree, the former impression, which was perhaps beginning to produce
sickness. Lemon juice and water, the different kinds of wines, punch,
pimento, cinnamon, and peppermint waters, milk, rose water, beer, &c.
afford us a variation which may be usefully employed.
The tincture and watery infusion of the bark, either separately or
mixed together, are frequently employed, when the powder is vomited;
but, as they must be given in very considerable quantities, in order to
produce any good effect, they are very apt to produce sickness, and
are likewise so inferior in power to the powder, that they are very
little to be trusted.
The extract with resin, is a better form than the tincture, or
infusion; and, where the powder is rejected, may be made into pills.
When the stomach rejects every form and preparation, it has been
proposed to give the bark in clysters, and this ought certainly to be
done rather than lose the effects of the remedy; but, given in this
way, its effects are more uncertain. From two drachms to half an ounce
of the powder of bark, may be diffused in three ounces of soup, or
mucilage, with fifteen or twenty drops of laudanum, and given as an
enema. This must be repeated at least every hour and a half, or two
hours, until the stomach can retain the medicine.
The wine is very usefully conjoined with the bark, and is even of
considerable use by itself, when the bark is rejected. Its operation is
more speedy than that of the bark, but it is perhaps more fugacious.
The quantity which is necessary to be given depends upon the effect of
the local disease upon the system, and on the inability to bear other
remedies. A table spoonful may be given in general every quarter of an
hour, unless it increase the pain, and frequency of pulse, and produce
restlessness, and heat of the skin. In these circumstances, we may be
certain that we have increased the quantity beyond the necessity[71].
[71] The necessity for this, and other remedies, is in general
proportioned to the continuance of the disease, and the progress which
it has made. In this, as in every other disease, we must be attentive
to the effects of our remedies, and consider these in forming our
opinion.
Opium is likewise an useful remedy in this disease, and ought never
to be omitted; because it not only diminishes the irritability, and,
consequently, the pain, but likewise, like the wine and the bark,
counteracts, by the induction of its peculiar action, the progress
of the inflammatio debilis, and, consequently, tends to check the
mortification. This medicine is most usefully exhibited in full doses,
which not only procure ease, but also frequently make the stomach more
readily bear other remedies. One grain of the extract, or twenty-five
drops of the tincture, may be given at once, and the dose repeated
whenever the action of the former subsides. After some time, each dose
must be increased one half, and presently doubled, in order to produce
the same effect as it did at first.
These remedies may give a temporary check to the disease; but, unless
nourishment be conjoined, in every possible form, they will not of
themselves be able to effect a cure, if the disease be tedious. Soups,
jellies, milk, sago, &c. must be assiduously given in small quantities,
and even thrown up as clysters, if the stomach cannot bear them.
Vegetable acids, fixed air, wort, &c. have been recommended in this
disease, probably upon the supposition of the existence of a putrescent
matter, or from their utility in scurvy. Wort, however, and fixed air,
do not appear to be of very great benefit in this disease, at least
they are by no means to be put in competition with other remedies of
more approved efficacy, or allowed to interfere with their exhibition.
The acid of lemons seems to be more generally useful than the carbonic
acid; and, perhaps, the nitrous acid would be equally useful with the
citric acid. These acids do not operate by counteracting putrefaction,
but by counteracting the action of descent, inducing a more healthy
action, and tending to excite ulceration, which is the mean employed
for separating the dead part, and producing restoration. For this
purpose, however, the acids must be given freely, otherwise no good is
done.
The local treatment is to be conducted on the same principle as in
the cure of the inflammatio debilis. Pledgets, dipped in the oil of
turpentine, tincture of myrrh, or rather in camphorated spirit of wine,
which is one of the best applications which can be used, ought to be
made use of.
These remedies can do little service when applied to the dead portion;
but, as the whole part does not die at once, there are always some
portions which are still in the inflamed state, and on which they act.
They likewise prevent the progress of the disease, by operating on
the skin which is contiguous to the gangrene. Every mortification, in
general, attacks the skin first; or, in other words, the inflammatio
debilis spreads faster along the skin than along the deeper parts; but,
when once the skin is inflamed, and mortifies, the disease extends to
a greater or less depth below the surface. Whatever, then, operates on
the surface, and prevents the progress of the inflammation, or cures
the part which is already inflamed, will tend to check the extension
of the disease, especially if the proper internal remedies be made use
of with a view to prevent the extension of the action of descent.
Formerly, in order to allow these remedies to come in contact with
the living parts, it was customary to make incisions through the dead
portion, and not unfrequently through part of the living substance.
But, as these cannot prevent the extension of the disease over a
greater surface, and, as the irritation which is given, and the
exposure of parts which have not yet assumed the ulcerative action,
tend to increase the inflammatio debilis, the practice must be
considered as improper[72]. It is now indeed almost universally laid
aside, owing, in a great measure, to the observations of the ingenious
Mr. Pott.
[72] The hot, and almost boiling oils, which were poured into these
incisions, contributed not a little to increase the disease.
Antiseptics, such as decoction of camomile flowers, &c. have been
recommended as external applications; but, whatever effects they may
have on the matter which is already dead, it is evident that they can
be of no service in preserving the living parts from suffering death.
All that can be expected from them is to check the putrefaction of
the dead substance, which they have very little power to do; and,
therefore, they can never come into competition with more valuable
remedies, such as the camphorated spirit of wine, &c.
When, by the use of the remedies already mentioned, the progress of
the gangrene is stopped, the ulcerative action is induced in the part
immediately adjoining to the dead portion, and a red line of separation
appears. By means of this ulcerative action, which takes place in
every point where the mortification stops, the dead part is separated
from the living, and comes away as soon as the bonds of dead muscular
fibres, tendons, &c. which unite them, are destroyed by putrefaction.
When this separation takes place, or when it is advanced so far as
to permit us to accelerate it by dividing the loose tendons, &c. the
exposed part must be dressed as an ulcer, or wrapped up in a poultice
of the same temperature with the human body.
If, however, the disease have penetrated deep, and destroyed the limb
so much as to render it impossible to cure it, or useless, if it were
possible, then amputation must be performed; but this, whatever desire
the patient may express, must not be practised until the mortification
be fully stopped, and the ulcerative action induced; because, if
performed sooner, the mortification seizes the stump, and the patient
is quickly killed. The system is likewise in such a state as to be
unable to sustain the action which is necessarily produced by the
operation. It is even improper to cut too near the diseased portion;
because the parts here, although the mortification be stopped, are so
weakened, that they are less apt to unite. The vessels often break out
soon after they are tied, and a new mortification is by no means an
unlikely occurrence. Even when the amputation is performed pretty far
up the limb, the corners of the stump frequently mortify, or become
livid; but a few doses of bark and wine stop the progress of the
disease.
Although it is a general rule that amputation is necessary whenever the
member is so destroyed as to become useless, and although this must
not be performed until the ulcerative action be induced, yet it must
not invariably be performed whenever this action takes place, because
sometimes at this period the patient is unable to sustain the general
action which the operation would produce. We must, therefore, if the
patient be much reduced by the extent, or long continuance of the
disease, rather delay until, by good diet, wine, &c. we have procured
an increase of strength; but, if we find that either the patient loses
ground, or his weakness remains stationary under this treatment, we
must then amputate; because, it is probable, that the continuance of
the dead portion in contact with the living is tending to induce still
the general action of descent[73].
[73] As an illustration of this rule, I may mention the following
case: A man, during a voyage to a cold climate, had both his feet
frost-bit, in consequence of which mortification ensued. In this state
he continued for two or three weeks, during which he received very
little medical aid. When I saw him, both his feet were mortified,
from the toes to about three inches above the ankle joints, his pulse
was feeble, very frequent, and intermittent, the strength was greatly
impaired, and the countenance sunk and ghastly. The ulcerative action
had been induced for some time, but the want of wine and proper diet
had prevented the system from gaining by the cessation of the local
disease. He began the use of the bark, opium, wine, and soups, which he
took very liberally, in consequence of which his pulse became slower,
and his strength increased. In two days, one of the ankle joints was
removed by clipping through the tendons, and, in a few days more, the
other came away. Amputation was now performed below the knee of the
right leg, the constitution, instead of gaining, rather beginning to
lose ground. The subsequent affection of the system was by no means
great, and, in about a week, he was much stronger; but, as the bones of
the ankle joint of the other leg were carious, he again began to sink.
Amputation was therefore performed on the left side, in about three
weeks after the first. During the cure, the wine, opium, and nourishing
diet, were freely prescribed.
When we do not deem it adviseable to amputate very soon after the
induction of the ulcerative action, it is sometimes useful to cut off
part of the black mortified portion, or perhaps to remove a joint, by
cutting through the remaining ligaments. In this way, we lessen the
fœtor, and make the patient more comfortable.
After making these observations on mortification, I shall conclude with
the following case:
A young woman, who lived at a considerable distance from Glasgow, was,
in May 1797, seized with erysipelas of the right foot and leg, which,
by her account, had been extremely violent, and very much neglected. On
the tenth day of the disease she was brought to town, and admitted into
the hospital. The foot was quite cold, the leg livid, and extremely
painful. Pledgets dipped in camphorated spirit of wine were applied to
the parts, and bark, wine, and opium, were prescribed, together with
oranges, &c. and gradually increased in quantity, until at last she
came to drink, besides soup, a couple of bottles of wine daily, at the
same time that she took eight grains of opium, and a very considerable
quantity of bark, in the twenty-four hours. By these means, the pulse
was soon brought down from one hundred and forty to one hundred and
eighteen strokes in the minute; but it was not until twenty days after
her admission that the ulcerative action was evidently induced. The
quantity of the medicine was now gradually diminished; and, in a few
days more, the separation being complete, the limb was amputated above
the knee. During the operation, I paid particular attention to the
saving of blood; and the circulation being destroyed in the parts below
the knee, there was scarcely any lost. At this time, she was still
taking a bottle of wine, with a considerable quantity of bark and
opium, daily. The wine was omitted after the operation; but she had a
drachm of laudanum, and continued to take the bark. In the evening the
same quantity of laudanum was repeated. Next day she was quite easy,
and had slept well; the pulse beat only one hundred in the minute. On
the third day the stump was dressed, when it was found (as was to be
expected[74]), that only a very imperfect adhesion had taken place:
One of the corners was also livid. The bark was therefore freely
continued, and six ounces of wine added daily; but the pulse having,
on the fifth day, risen to one hundred and ten, and the spot becoming
of a darker colour, she was allowed a pound of wine, which made the
pulse fall, and soon produced a separation of a small slough. In a
short time she went to the country cured. During the whole period of
the cure, the opium and wine which she took produced neither stupor,
nor the slightest appearance of intoxication. I at one time, when the
pain had for a couple of days been moderate, was willing to ascertain
the effects of a milder preparation than the camphorated spirit, and
substituted proof spirit in its place; but, in an hour, it was obliged
to be renewed, the pain having greatly increased.
[74] It is very seldom that a stump unites at first, if amputation be
performed on account of mortification; at least if the operation be
not delayed until the health and strength be fully re-established:
But this can very seldom be the case; for, in most cases, the state
of the bones, and the disease of the part itself, prevents recovery
from taking place beyond a certain degree, and also prevents us from
delaying beyond a limited time. The system, therefore, is not allowed
to recover fully from the tendency to the action of descent, and union
does not take place. In the case which was formerly mentioned, the
first stump did not adhere fully, but the second succeeded better,
because then the system suffered more from the state of the diseased
bones, &c. than from the previous mortification, and, therefore, it had
not the same inability to undergo the healing action.
_Of the Treatment of the Inflammatio Assuefacta._
After the inflammatio valida has continued for a considerable time,
if neither suppuration, nor any other termination be induced, it is
very apt to be converted into the state which has been called passive
inflammation, or which, on account of its most frequent cause, I have
called the inflammatio assuefacta. This action is, in several respects,
different from the acute inflammation, and resembles it only in its
general appearance. It may therefore, in one respect, be considered as
a termination of inflammation, being, strictly speaking, a new action,
or spurious inflammation.
This action succeeds the acute inflammation, sooner or later, in
different places; and, when once induced, each succeeding inflammation
of the same part is apt very quickly to terminate in the same
condition; or, if the renewal of the inflammation be very frequent,
this is at last induced without any previous acute inflammation.
A state somewhat similar to this, if not exactly the same, precedes
acute inflammation, as well as follows it; for, during the period
which intervenes betwixt the first formation of the action and its
perfection, the part remains in this state. We can sometimes observe
the augmentation and diminution of the redness and pain during the
systole and diastole of the arteries; and, by the use of the same
remedies which cure the inflammatio assuefacta, we can sometimes
prevent the farther progress of the disease.
Thus, pepper boiled in milk, is frequently used by the country people
as a cure for cynanche, during its incipient stage.
Bleeding, saturnine applications, and the other remedies which are
useful in the inflammatio valida et acuta, are hurtful here, and
increase the disease.
The agentes similes, on the contrary, are useful, and may be used
internally, or topically.
Internally, the bark, wine, and opium, with good diet, ought always
to be employed, if the part affected be very delicate, and sympathise
greatly with the constitution, or if the extent of the disease be great.
Locally, stimulating applications are the proper remedies; and the
strength and nature of these must depend upon the natural or acquired
delicacy of the part.
When the skin, or cellular substance, is affected with the inflammatio
assuefacta, spirit of wine by itself, or with the addition of a little
camphor, is a very useful application.
When the skin is not directly affected, but only the parts immediately
below it, as, for instance, the muscles in chronic rheumatism, or the
articulating surfaces of joints, we may sometimes, by applying cloths
dipped in laudanum, or strong diffusion of opium, propagate, from the
surface to a certain distance, the narcotic action, and alleviate
the disease; but, most frequently, we are obliged to trust entirely
to the effect of the sympathy of equilibrium, diminishing the action
of the internal parts, without any considerable change of nature, by
increasing that of the surface. Blisters and rubefacients, such as
volatile linamentol. terebrinth. cum camphora, &c. are the remedies
for this purpose.
The inflammatio assuefacta, when it affects delicate parts, covered
only with a thin skin, such as the throat, forming one of the most
frequent species of cynanche, is cured by gargling with port wine,
infusion of capsicum, and similar remedies.
When it affects the eyes, the use of stimulating and opiated
preparations have been long in use. The following is one of the best:
R. Vini Albi uncias duas.
Opii drachmam.
Pulv. Gall. scrupulum. Macera per dies tres dein cola.
A drop or two of this may be let fall into the eye three times a day.
Electricity is recommended in the cure of this kind of inflammation;
but this, as well as heat, are doubtful remedies; for both seem to
increase actions without changing them, except in so far as the change
depends upon an increased degree. Cold, on the other hand, lessens the
power of recovery, if carried to any great degree; but, when slight, it
assists the operation of other remedies, by lessening the performance
of the existing action, which is morbid. All applications, therefore,
ought in general to be a little below the temperature of the part.
Whenever an inflammation does not manifest a tendency to any other
termination, but continues stationary, or perhaps becomes worse, under
the use of the remedies which we employ for the cure of the inflammatio
valida, we may consider that this action (or the inflammatio
assuefacta) has taken place, and that the nature of our applications
must be changed. Bark and wine, with anodynes, may be given internally,
whilst, if the situation of the part permit, suitable applications must
be made to it. By continuing this treatment, we frequently resolve the
inflammatio assuefacta; but, occasionally, it becomes again converted
into the true acute inflammation, in which case the continuance of
the same remedies will do hurt. The appropriate local remedies, such
as cold, saturnine preparations, &c. must be had recourse to, if the
part be external, whilst, if the pulse become hard, and more frequent,
or fuller, general remedies, such as bleeding in small quantity, may
be useful; but both local and general remedies must be used with
moderation, and pushed only a certain length, otherwise we defeat our
intention, and again speedily induce the inflammatio assuefacta, by
interfering with the powers of recovery. If this happen, we must again
have recourse to the proper remedies.