_On the Phagedenic, and some other Species of Specific Inflammation._
When any peculiar modification of the inflammatory action takes place,
specific inflammation is said to be produced; that is to say, the
action possesses some peculiar or specific qualities, independent
of the simple condition of inflammation; and these are generally
productive of evident and visible effects, which are characteristic
of their presence; but, until these effects, which are chiefly
observable in the appearance of the consequent ulceration, appear, it
is frequently impossible, from the symptoms of the inflammation alone,
to say that it is specific; because the evident effects, or symptoms of
the inflammatory action, such as heat, pain, redness, &c. admit of few
specific alterations, varying only in degree, and this variation taking
place often without any specific affection of the action[75].
[75] In most specific inflammations, if not in every one, the redness
is never of the bright scarlet colour, but always more or less purple,
or dusky; but this may take place without any specific action. The
sensation is also sometimes different.
The effects of the ulcerative action admit of greater variations than
those of the inflammatory, and, therefore, more readily show the
presence of specific action. The healthy ulcerative action exhibits
certain appearances which have been already described, and which are
easily known. The simple deviations which have been treated of, in
considering the different genera of ulcers, are also discoverable by
the effects, or peculiar symptoms. The specific deviations dependent
upon the presence of previous specific inflammation, or the application
of a morbid agent, after simple ulceration has been induced, may
also, in many cases, be detected and ascertained, by the variations
which take place in the aspect of the sore, the appearance of the
granulations, discharge, &c.; but these variations and appearances
consist so much in peculiar hues and qualities of the granulations,
which we have no words to convey an idea of, that it is impossible
to give an accurate description of a specific sore, but must see it
in order to obtain an idea of it. We may indeed say, that a sore is
ragged, has a fiery look, is surrounded with an erysipelatous margin,
and discharges a thin fœtid matter, but still we shall not convey the
idea of the specific appearance of the ulcer.
It is this specific appearance alone which characterises a specific
ulcer; and this, in each peculiar ulcer, is different; and a knowledge
of it can only be obtained by an attentive examination of many sores.
On this account, it is extremely difficult, in many instances, to
distinguish a specific ulcer, because the discrimination depends
altogether upon the recollection of the practitioner, and the
improvement which he has made of his former observations. It is indeed,
it may be thought, an easy matter to distinguish a simple ulcer by
negative characters, or the want of the peculiar aspect; but, as this
aspect is very arbitrary, and as the appearance of simple ulcers is,
as has been already described, very various, it is difficult to say,
without much judgment, whether the sore be simple or specific; for
the appearance of the one and of the other run imperceptibly into each
other. Even if it be ascertained to be specific, it is difficult often
to distinguish betwixt particular specific diseases, in so much, that
many are forced to take mercury for the cure of syphilis, who never had
that disease.
Besides the appearance of the sores, specific action likewise produces
a perceptible effect upon the scab which covers them, or the cicatrix
which is formed. Thus, scrophula is marked by a particular appearance
of the cicatrix, or of the scab. The venereal ulcer has likewise a
particular scab, and many cutaneous ulcers are best distinguished by
the scab. Other actions produce no considerable ulceration, but only
successive desquamation of the cuticle.
We may also sometimes discover specific action by the sensation of
which the action is productive. Thus, for instance, cancer produces a
burning kind of pain, which never attends simple ulceration.
Specific ulceration is also always surrounded with more or less simple
inflammation, or erysipelas, of the surrounding skin. In some cases the
margin is hard, in others ragged, &c.
It were much to be wished, that some more certain, and less arbitrary
criteria, than those which we possess of the presence of specific
action could be discovered; but, as yet, we know of no other which can
be applied universally. Some kinds, indeed, are so well marked, and so
peculiarly distinguished from simple sores, that they can be tolerably
well described, and easily discovered to be specific; but, there are
others which it is more difficult to ascertain, owing to the difficulty
of fixing the character of each individual action.
The number of specific inflammations is very great, and the causes
which produce them are often obscure. In the preliminary dissertation
it was mentioned, that, whenever any action existed strongly in any
one part, it tended to induce an inflammatory state. There are,
therefore, no general, or febrile diseases, which may not be attended
with peculiar inflammations. That typhus fever is attended with
local inflammatory action is pretty certain; but the presence of
specific inflammation is still more evidently seen in the different
exanthematous diseases. The diseases called cutaneous, afford us also
numerous instances of specific inflammation.
From the difficulty of discriminating betwixt diseases, which, although
essentially different from each other, yet possess a very great
similarity, we find, that the number of specific inflammations is
confined much within the true limits; for we find many confounded under
the name of herpetic, &c. which are radically different from each other.
Phagedena has been used by medical writers in a very extensive sense,
and has been made to comprehend diseases, which, strictly speaking,
cannot be considered phagedenic.
The phagedena is a suppurating sore, dependent upon the application
of a peculiar contagion. No granulations are formed, but both sets
of vessels yield a thin fluid. The surface of the sore has a jagged
appearance, dependent upon the irregularity of the absorption, and
not upon the deposition of organic particles, or granulations. The
colour of the surface is dark, but clear, or fiery. The surrounding
integuments are erysipelatous. The discharge is thin and serous, and
the pain considerable. This is divisible into two varieties: First, the
true phagedenic, which does not go deeper than the skin, but spreads
rapidly along the surface. This kind frequently stops in its progress
suddenly, and skins over as fast as it spread. Second, the noma, or
penetrating phagedena, which extends deeply, penetrating sometimes
perpendicularly down through the cellular substance to the muscular
fascia; at other times, proceeding more irregularly, penetrating
deeper at one part than another, and having its margins ending less
abruptly in the neighbouring skin. This never cicatrizes rapidly; but,
sometimes, when the sore assumes a healing appearance, it suddenly
becomes again diseased, and a considerable portion sloughs off. The
alternation of proceeding a certain length in the cure, and relapsing,
is frequently repeated, and often renders the disease very tedious.
The best application for the common phagedena is an ointment consisting
of an ounce of ung. resinos. and a drachm of red precipitate.
The application of caustic to the surface also frequently stops the
progress of the disease.
The hepatized ammonia, much diluted, is also very useful as a lotion.
The penetrating phagedena is more difficult to cure; for, even after
the diseased action is removed, the ulcer remains in an irritable,
or overacting date. The application which I have found most useful is
powdered opium, mixed with simple ointment, in the proportion of two
drachms of the former to an ounce of the latter. After the phagedenic
action ceases, the sore must be treated according to the genus of
simple ulcer to which it belongs.
When the sores seem to pursue their ravages obstinately, the most
effectual mean of stopping their progress (until we discover a specific
remedy, or one which can change the nature of the action), is to apply
the caustic to every part, and so freely, as to produce a pretty thick
slough. Whenever this appears to separate, precipitate must be applied,
in order, if possible, to prevent the recurrence of the diseased
action.
When any considerable vessel is eroded, by the continuance of this
disease, it must be tied beyond the diseased part; but we must be
careful that no matter from the sore gets upon the wound, otherwise it
will become diseased also. I have a preparation, in which a part of
the femoral artery was opened at the groin by this kind of sore, which
succeeded a venereal bubo. No operation, I understand, was attempted,
but compression alone used. The man died in a short time. Whether tying
the iliac artery, by cutting through Poupart’s ligament, would have
saved him, is difficult to say.
The true phagedena seems always to confine its action to a particular
spot[76]; but many of these diseases, which have been described under
the same name, appear to be capable of inducing a general action,
similar to the venereal disease, affecting different parts of the body
in succession. A case of this kind is related by Mr. Adams, in his
Observations on Morbid Poisons: A gentleman who had a small pustule on
the prepuce, squeezed it so as to make it burst, and soon afterwards
had connection with a woman whom he had long known. The sore remaining
without healing, he applied a solution of caustic, and had recourse to
mercurial frictions. But, notwithstanding these, the ulcer spread, and
soon reached the scrotum. The mercury was now laid aside, and bark,
with a good diet, were substituted, after which the ulcer put on a
healing appearance; but, before cicatrization took place, a feverish
fit supervened, with violent pain in the part. In the course of a
short time, however, the unfavourable symptoms disappeared, and a
healthy condition was again apparently induced. These paroxysms of
fever, and subsequent amendment, alternated with each other for a
considerable time, and each relapse was preceded by a livid appearance
round the sore. These appearances at last went off, and the sore
assumed more the aspect of the true phagedena. The cicatrizing process
now began at the upper part, and proceeded rapidly until almost the
whole sore was covered. But, nearly about this time, copper coloured
spots appeared on the hands, and the inside of the right thigh; and,
in a day or two afterwards, an ulcer appeared in the throat, with
“bumps” on the head. Shortly afterwards a node appeared on the tibia,
and the patient became bandy. The blotches speedily began to ulcerate,
and another appeared on the sternum. Mercury was now given freely,
and at first with apparent success, for the ulcers looked better,
and no new affection appeared; but, whenever the mercurial action
was beginning to be fully induced, the granulating appearance of the
surface was destroyed, and it became of a dusky colour, discharging
“bloody sanies.” The bones remained stationary. The medicine was
now discontinued, and the patient went to the country; but, on his
return, in about a fortnight, “his throat was again ulcerated[77].
Such of the old external ulcers as had not healed, threw up a kind
of fungus granulations.” The sore on the penis, which never had been
completely well, had spread to the size of a shilling, but had no
phagedenic, or specific appearance. Mercury was afterwards tried,
and some bones exfoliated from the nose. The ulcer healed; but, as
soon as he recovered from the effects of the mercury, new blotches and
ulcerations, with a new enlargement of the tibia, took place. “He is
now under his fifth mercurial course.”
[76] The neighbouring glands sometimes swell and suppurate, but they
heal kindly, and the disease proceeds no farther.
[77] From this, it would appear, that his throat had been at one time
healed.
In this case, mercury evidently was prejudicial, except toward the
end. It does not appear that the caustic had been freely applied to
the original local disease, which might have destroyed it. These
affections, which were by some considered as venereal, evidently
differed from that disease, in the rapidity of its progress, in the
appearance of the primary sore, and in the history of the whole of the
symptoms. We are as yet in the dark with regard to a specific remedy
for these, and similar affections.
There are several other ulcers, which appear upon the penis after
coition, which probably depend upon the application of a peculiar
contagion. These[78] are sometimes superficial and phagedenic; they
spread fast, and heal rapidly, frequently in the course of a night
after precipitate has been applied. At other times they are deeper, and
more like a little cup; the surface is smooth and glossy, without any
appearance of granulations; the discharge is thin, and the base and
margin quite soft. The best remedy is the caustic, with the subsequent
application, precipitate, or ung. hyd. nit. dilut. When buboes form, I
have always found them heal without the use of mercury. If, however,
the bubo be the first symptom which appears, as is sometimes the case,
(for the morbid agent is occasionally absorbed before it excites action
in the part to which it is applied), then it is generally much more
difficult to heal than when it is preceded by a local action, and
induced by the absorption of matter generated there.
[78] Many of these have been confounded with the venereal disease, and
treated accordingly.
It were much to be desired that they should be accurately described,
and one kind distinguished from another, for there are probably many
different species.
If these local, or primary symptoms, be not speedily removed, a general
disease is induced, as we see in the case already mentioned, and as
is proved by numberless other instances. These general affections
are marked by ulcerations of different parts; and the ulcers have a
different appearance, according to the nature of the morbid agent. In
some cases they are better and worse at intervals. Mercury has, in
almost all these cases, been used; but, although some are ameliorated
by it, yet others resist its action. At first, indeed, they generally
appear to heal; for the mercurial action, when forming, interrupts the
progress of the former diseased action; but, whenever the mercurial
action is fully induced, we sometimes find that the appearances change,
and the progress generally becomes quicker than formerly[79].
[79] Some actions cannot be induced during the continuance of others.
Other actions can, in these circumstances, be formed, and displace
completely the former action. A third set seem to give a modification
to the original disease: They change it to a certain degree; but the
change is not salutary, and they never displace it. The mercurial
action, when induced during the existence of some of the diseases
which I am describing, comes under the last, or third class. At first,
during the formation of the mercurial action, the former diseased
action is interrupted, in the same way as the natural action is injured
during the period of formation of other actions, when no peculiar
disease previously existed. On this account, the sore assumes a better
appearance; and, if the action be nearly terminating naturally (as some
actions do, and as the primary action in these diseases more readily
does than the secondary), it quickly heals up; but, if this be not the
case, the appearances soon change, and the disease becomes much worse.
There is a disease which is not unfrequently confounded with syphilis,
but which is distinct from it; I mean small ulcers about the mouths
of children, which are more like aphthæ than any thing else; but,
soon after their appearance, small blotches appear in the body, which
become first raised into a little flat vesicle, and then ulcerate
superficially. These ulcers have a watery appearance, not much unlike
tetters; but the appearance of the vesication, and dark colour of the
preceding blotches, prevent any confusion. Nurses who suckle these
children have generally small calyciform ulcers on the nipples, of
a pale colour, and discharging a thin watery matter. I have had no
opportunity of ascertaining what constitutional symptoms would be
produced by the continuance of the disease in the nurse, as I have
generally found that the application of diluted citrine ointment
to the nipple produced a cure, without any internal medicine. The
constitutional symptoms in the children were cured by the same local
applications, with small doses of calomel internally[80].
[80] There are some cases, described by different authors, of
affections of the nipples and breasts, in which the ulcers appear to
have been chiefly of the phagedenic kind.
I have likewise observed ulcers on the lips, throat, and mouth,
which at first had a very doubtful appearance; but they evidently
are distinct from syphilis, and belong to the suppurating sores.
When superficial, the buff-coloured matter, or inorganised substance
which covers them, has a fibrous, or thready appearance, the margins
are slightly tumid, and of a florid, or kind of pink colour. The
application of caustic, or burnt alum, is often sufficient of itself to
cure these; but small doses of mercury sometimes accelerate the cure.
At other times these sores penetrate deeper, and affect the bones. The
surface, which is deep, is covered with a thick yellow slough, like an
overacting ulcer. The margins are tumid, ragged, and of a light, or
pink colour. Sometimes the disease spreads along the gum, which becomes
soft, ulcerated, and separates from the teeth, which very frequently
become black, and, when the sockets are affected, drop out. I have not
had an opportunity of observing these sores go the length of inducing
constitutional symptoms. It is not easy to ascertain the cause of these
sores; sometimes they succeed the use of mercury; but, at other times,
it is impossible to blame any evident agent. The transplanting of teeth
sometimes has been the mean of inducing sores similar to these; and,
in these cases, the disease has generally passed for syphilis[81].
But although the venereal disease may have been inoculated in this
manner, it is certain, from the appearance of the ulcers, from their
rapid progress, and from the sudden effect produced by a very small
quantity of mercury, that the disease, which is commonly induced by
transplanting teeth, is not syphilitic.
[81] Cases of this kind may be found in Mr. Hunter’s Treatise on the
Venereal Disease, and in the third volume of the Medical Transactions.
Sibbens is another disease which has been very frequently confounded
with syphilis, and is by many considered to be only a variety of that
disease; but they evidently are different, as appears from the mode of
infection, and the properties of the contagion[82], the appearance of
the ulcers, their progress, and certain circumstances in their cure,
particularly their requiring less mercury than venereal ulcers in the
same state, and from their yielding readily to preparations of mercury,
which do not accomplish a cure of syphilis.
[82] This disease is communicated even by drinking out of the same
vessel with an infected person, even although that person have no sores
on the lips, but only in the throat. The contagion then must either be
dissolved in the saliva, or remain very powerful, even when reduced to
a state of halitus.
This disease appears first on the part which is most directly acted
on by the contagion. This part becomes red and inflamed, having
an erysipelatous appearance. Ulceration quickly takes place on a
particular spot, and spreads rapidly along the whole inflamed part.
The disease then advances more slowly; the erysipelatous appearance
spreads around the margin of the ulcer, and ulceration follows upon the
inflammation. In the course of some time (the precise period is not
fixed), the skin becomes affected with blotches, or sometimes clusters
of small pustules, the intervening space betwixt each being affected
with an erysipelatous inflammation. These spots soon ulcerate, and
the surface rises up into a fungous, which is irregular, and has an
aspect somewhat betwixt the look of the venereal sore and a very bad
scrophulous ulcer. The bones next become affected, particularly at the
articulating surfaces, which swell, and become carious. It is said that
the secondary ulcers in general appear first upon the genitals; but,
of all those whom I have examined, no affection of these parts had
taken place, from which I would infer, that the disease has no peculiar
tendency to affect these in preference to other parts. It is likewise
said that the disease sometimes disappears from one part, whilst it
breaks out in another; but this also I have never witnessed. The
primary ulcers also have no tendency, like some others, to change their
appearance, and become milder, or heal by continuance, but spread,
destroying the nose, orbits of the eyes, and face. The constitution
seems to suffer much more from this disease than from syphilis, in the
same length of time; for the patient soon assumes a pale sallow look;
and hectic comes on much sooner than in syphilis.
The cure of this disease is effected by washing the sores with
solution of corrosive sublimate, or dressing them with precipitate
ointment, at the same time that we use mercury internally, without
which no escharotic, or local application whatever will effect a
cure. In general, less mercury cures this disease than syphilis; and
it is worthy of remark, that permanent cures may be obtained by the
hyd. mur. corros. which is not the case with syphilis. When the bones
are affected, we must, in conjunction with the specific remedy, use
such applications as the state of the bone, considered as a simple
affection, will require.
The cynanche maligna, and scarlatina, are also diseases producing
ulceration in the throat. The sores are of the suppurating kind, a
thick lymphatic-looking, or inorganised substance being thrown out,
instead of organic particles, or granulations. This, in the former
disease, very soon becomes black, and putrefies; but the slough so
formed differs materially from that caused by gangrene; for, in this
disease, unless in the very last stages, there are no real gangrenous
sloughs. It is unnecessary here to make any particular observations on
these diseases.
Herpes[83] is a disease which is very frequent, and often prevents
large ulcers from healing, as these come to assume the action of
herpetic ulcers, although, from their magnitude and depth, they do not
put on the same appearance as when the disease is confined to the skin.
The large ulcers are of a dark sloughy appearance, discharge thin
matter, are painful, and are surrounded with herpetic ulcers, and scabs
in the skin. This is a very frequent disease on the legs, and is very
tedious. Bathing with warm sulphureous water is often of service, at
the same time that we dress the parts in the intervals with camphorated
ointment. Citrine ointment is also very useful; but the following
liquor is one of the best, and most effectual applications:
[83] There are many different divisions of herpes; as, for instance,
into the scurfy, scabby, miliary, &c.; but, for a description of these,
I must refer to the writers on the diseases of the skin.
R. Pulv. Calcis Vivi Recen. unciam.
Flor. Sulph. semiunciam.
Aq. Font. sesquilibram. Coque ad dimidiam dein cola.
This ought to be applied with cloths to the parts.
When, by these means, the disease of the skin, and the specific action
of the ulcer is removed, pressure is often of service in completing
the cure.
There is a specific ulcer, which is met with most frequently on the
legs, and which is very troublesome. The skin becomes in several points
inflamed, or of a dark red colour. These parts speedily ulcerate, and
the sores belong to the suppurating kind, for no distinct granulations,
or organic particles, are formed; but the surface is smooth and glossy,
and the discharge thin and copious. These sores are generally pretty
deep, in proportion to their extent, or of a cup-like appearance. They
not unfrequently occur in scrophulous habits. Mercury, exhibited in
small doses internally, appears to be useful. Precipitate, as a local
application, generally answers very well; but, when the sores become
irritable, or spread under this treatment, hemlock poultices succeed
better.
There is a small ulcer, which sometimes is met with on the foot,
of an irregular shape, fiery appearance, and surrounded with thick
jagged margins, which, in particular parts, are white, and callous.
The neighbouring integuments are of a dark red colour. The discharge
is thin, and the pain considerable. Caustic, and afterwards the
application of the adhesive plaster, are the best local applications.
Internally, the use of hemlock is sometimes of service.
It occasionally happens, that, nearly about the same time, most of the
patients in a ward of an hospital shall have their ulcers rendered
unhealthy. They become foul, dark coloured, and spread: The discharge
is thin, and the pain is greater than formerly. The application of
cloths dipped in gastric juice is sometimes of service in these sores,
and is one of the best remedies; but, not unfrequently, the patient
must be removed to a different situation before a cure can be obtained.
Having made these detached remarks on some specific ulcers, I shall,
in the succeeding dissertations, consider, at greater length, others,
which are, in the general estimation, considered as more dangerous and
alarming.