of wounds by granulations was considered, p. 173. They heal more
readily on the upper extremities, on the face, neck, and trunk, than
on the lower limbs; for in the former parts the circulation is more
vigorous, the natural processes of cure proceed more easily, and are
less liable to interruption. The sore only requires rest, a clean
condition of the surrounding parts, mild and light dressings, and
moderate support; dry lint or lotions are preferable to ointments,
since the latter are apt to irritate by their rancidity. When the sore
is of considerable size, and there is a tendency in the granulations to
rise above the level of the surrounding skin or cicatrix, the edges may
be protected by very narrow slips of fine old linen or cambric, spread
with fresh spermaceti ointment or cold cream; a pledget of dry lint is
then laid on, and retained by a roller. The dressings thus arranged
do not adhere, and the tender cicatrix is not ruffled and disturbed;
or a piece of pierced linen spread thinly with unirritating ointment
may be placed over the sore, and above that dry lint. When the sore
has contracted to a small size, and some powder, as starch or calamine
stone, or a piece of dry lint, may be applied, so as to allow a scab
to form for the protection of the subjacent surface; but this will,
in most cases, be better accomplished by touching the surface lightly
with lunar caustic or blue stone; the fluids on the part are thereby
immediately coagulated, a crust is quickly formed, and by covering it
with charpie, it is retained in its situation, whilst the process of
cicatrisation proceeds beneath it: if a small quantity of matter should
be secreted, it readily escapes by the sides of the crust, without
disturbing either it or its covering; the limb should be raised above
the level of the trunk. Sores on the lower limbs are always difficult
to manage. The reparative process is tedious, on account of their
situation; the parts are at a distance from the centre of circulation,
their action is weak, the return of blood is tardy, and the same
facility is not afforded of restraining the motions of the part as in
the upper extremities. In persons of a good constitution, however,
the simple purulent sore often heals speedily, even in the lower
limbs. Before cicatrisation can take place, it is essential that the
granulating surface should be on a level with the sound surface around;
this soon takes place when a favourable position is observed, and the
part is kept at rest; but by neglect, the new matter is often absorbed.
Again, the healing process cannot advance where the granulations are
exuberant, large, and flabby, and have risen above the proper level:
they must be kept in check by due compression, and by astringent
lotions, containing salts of zinc, copper, &c. The constant meddling
with sores, the touching them with this, that, or the other caustic, is
much to be reprobated. Should it be necessary to destroy granulations,
and bring them down to the surrounding surface, one good rubbing with
the blue stone will generally suffice. If the ulcer is large, the
granulations close to the cicatrix should only be destroyed, leaving
the centre to be dealt with as the cure advances.
During the cure, the patient must be a good deal confined to the
recumbent posture; when erect, a bandage or laced stocking must be
applied to the limb; thus the return of blood is assisted, swelling
is prevented, and the affected parts placed in a state of comparative
rest. Much pressure ought to be avoided, as it is apt to produce
bad effects upon the sore, causing absorption of the granulations,
thin bloody discharge, and great tenderness of the surface. After
cicatrisation, the scars may be absorbed, and sores reproduced, by
external injuries, or an unhealthy state of the body; and so much does
the state of a sore depend upon that of the general health, that the
one is a good index of the other.
II. In the second class of sores, or those with weak action, the
granulations are flabby, of a pale colour, and possessed of little
sensibility or vascularity; the discharge is gleety, and the surface is
liable to be destroyed by ulceration or sloughing, upon the slightest
excitement of the circulation in the part. The surrounding integuments
are generally of a bluish colour, in consequence of their separation
from the subjacent parts; and in several places of the neighbourhood,
small, unhealthy, detached abscesses may exist; at some points of the
sore, glairy fluid is seen to ooze out on pressure, and a probe can
be passed pretty deeply into the cavity of an abscess in the soft
parts beneath. These sores may arise from an unhealthy condition of
the cellular tissue, taking place spontaneously, or following slight
injury; they are attributable to the state of the constitution, and
may result from an ulcer, originally of a healthy character, which
has remained long open, in consequence of its great size, or other
impediments to its contraction.
It is the business of the surgeon, in cases of this description, first
to obtain a sound foundation, by destroying the unhealthy skin and
cellular tissue; the free application of caustic potass will answer
this end most readily and effectually. Its application is attended with
considerable pain, but the practice is more successful and less severe
than the removal of the unsound parts by the knife or other means. The
small abscesses may be all freely laid open; the diseased cellular
tissue may be cut into, or cut away; in short, incisions may be made in
all directions, and in every portion of the affected part; but still
it will be found that the granulations, as they appear, become pale
and flabby, that they spring from a loose and powerless base; matter
will again collect; the surrounding skin will again be undermined; no
progress will be made towards soundness. But by attention to the state
of the constitution, and the application of potass, the neighbouring
sound parts have their actions roused, and the healing is carried
on rapidly. After its application, a poultice may be applied for a
few days, and followed by water dressing, and then stimulants, both
internally and externally employed according to circumstances, the
parts being all along well supported. The long continued use of warm
fomentations, or poultices, is prejudicial, as tending to diminish
still farther the action of the parts; ointments can be of little
service, and will generally do harm.
III. Indolent ulcers, which have long existed, are frequently met
with on the lower limbs. Their margins are thick and insensible—their
surfaces smooth, hollow, and of a pale colour—the discharge is
scanty, and adheres to the surface. A sore, having been long open and
neglected, degenerates into this state. Poultices are to be applied for
a day or two, to clean the surface, promote the discharge, and soften
the callous margins. This is the more necessary, if, as is often the
case, the sore, or the surrounding integuments, are inflamed when the
patient applies for relief. Afterwards, the applications must be of
such a nature as to moderate the discharge and keep the granulations
firm and healthy. In such cases only is adhesive plaster applicable,
and in them it produces the most beneficial results. Supposing the
ulcer to be situated on the fore and middle part of the leg, a bandage
should first be firmly applied from the toes to a little below the
sore; the ulcerated part of the limb is then encircled by narrow
strips of adhesive plaster, tightly drawn, and with the extremities
of each strip crossing immediately over the ulcer. A pledget of tow
is placed on the plasters to absorb the discharge, and the bandage is
brought over dressings, and continued for some way upward. By this
application, the margins of the sore, it is supposed, are brought
nearer to each other, and the ulcerated surface diminished; the
sluggish granulations and the subjacent parts are stimulated, and a
more vigorous action being excited, the process of reparation proceeds
speedily and effectually; the surrounding parts, previously turgid
and œdematous, are by the pressure brought to the same level with the
newly-secreted matter, and new skin is quickly formed. In the previous
state of matters, the old skin was much elevated, and an action was in
progress, causing a continuance of that elevation; by the compression,
the whole limb is properly supported, serous effusion prevented,
absorption excited, and œdema removed; the livid swelling of the lower
part of the limb, which might arise from the tightness of the adhesive
plaster, is obviated by the bandage being first applied. A feeling of
uneasiness in the limb sometimes follows such dressing, but is of short
duration; should it increase, so as to amount to pain, the elevation of
the limb and the pouring of cold water occasionally over the dressings
will soon restore the parts to comfort. Or the adhesive plaster may
be slit up behind, immediately after its application; indentation of
the limb being thereby avoided, and sufficient pressure at the same
time kept up on the sore. If possible, the dressings ought not to be
removed before the second day, as much irritation will be produced
by their frequent renewal. The benefits arising from this mode of
treatment are truly surprising; the slow and indolent ulcer is speedily
converted into the simple purulent sore; the white and recent cutaneous
substance encircles small pointed and florid granulations, which bleed
from the slightest rudeness of touch; and the space formerly occupied
by an unsightly sore is soon diminished to a small and firm cicatrix.
It is only necessary to continue this mode of dressing so long as the
granulating surface is below the level of the surrounding surface.
Then the object being attained, the deranged state of the cellular
tissue being got rid of, and the ulcer put in a state favourable for
cicatrisation, the sulphate of zinc lotion not over strong may be
resorted to; positive rest and support of the affected part being still
enjoined and observed. In the old and debilitated, however, in whom the
indolent sore most frequently occurs, the integuments remain purple
and shining, and from very slight causes the cicatrix is absorbed, and
breach of surface is reproduced.
These sores are often connected with a varicose state of the veins.
In all such cases, a degree of compression on the affected limb must
be maintained, both during the continuance of the sore, and after it
has healed. The usual situation of such sores is on the leg, and the
varicose state of the veins does not, in general, extend above the
knee; in such cases, a radical cure may be attained (provided the
patient wishes to encounter the attendant risks, rather than submit
to a continuance of the disease) by effecting an obliteration of the
saphena major vein. The manner of doing this, and its effects, were
mentioned while treating of diseased veins. In some cases, the saphena
minor is also varicose to some extent, the varices on which must also
be obliterated. Sometimes as many as eight or ten needles must be
applied, in pairs, before the circulation of a limb can be brought into
a right state.
IV. In this fourth class of sores, or the irritable from over-action,
the sore and its edges are of a jagged, irregular appearance, the
discharge is thin and bloody, and considerable pain is experienced.
This ulcer is very superficial, involving only the surface of the
corium and the more sensible part of the integument, the papillæ,
and extremities of the nervous filaments. They often succeed to
scaly eruptions, and present a remarkable character and appearance,
cicatrising in the centre, whilst they extend towards the
circumference. The sore is often covered by an ash-coloured slough;
on the removal of which, granulations arise, but these either again
slough, or are removed rapidly by the ulcerative process. In the
treatment of such sores, complete rest and soothing applications
are the means on which most reliance is to be placed. Warm and
soft poultices, such as those of arrow-root, fomentations, tepid
water dressing, solutions of opium, or of extract of poppy, and the
occasional use of a local vapour bath to the part, may be enumerated
amongst the means best fitted to allay the irritable condition of the
ulcer. When the surrounding integuments are swollen, red, painful,
in short, evince marks of inflammatory action going on in them, the
feelings of the patient will be rendered grateful, and the cure
advanced, by abstraction of blood from the parts by punctures. When the
nature of the sore is changed, and when cicatrisation has commenced,
the treatment is similar to that of a simple granulating surface—light
dressings, due support of the parts, and repression of exuberant
granulations by the sulphate of copper. The nitrate of silver, applied
in substance round and about the ragged edges, is of great service at
an earlier period. This practice must be sparingly and seldom resorted
to, but it does wonders when judiciously employed.
Ulcers are occasionally prevented from healing by the presence of dead
portions of tendon, fascia, or cellular tissue, and are accompanied in
general with a bad state of constitution; in such it is necessary to
clean the surface by a powerful escharotic, and the best is potass.
Otherwise, granulations will be produced quickly, it is true, and in
abundance, to supply the original substance; but then they are flabby
and exuberant, new skin is formed slowly, if at all, and the sore does
not contract; but by removing the dead or half-dead surface, a healthy
and firm foundation is prepared, on which is securely and gradually
raised the new matter for cicatrisation. But caustics are applied
injudiciously to firm and healthy granulations which have not yet
reached the level of the surrounding parts; they are only useful in
repressing exuberant granulations, or in destroying half-dead parts,
which interrupt or deteriorate the cure: and when employed, it should
be effectually, and once for all.
Along with the topical treatment of ulcers, internal means are, in
most cases, indispensable. Thus, in indolent ulcers, the state of
the constitution is often sluggish, and ought to be changed by the
exhibition of alteratives or stimulants; with this view, much benefit
is derived from a prudent and restrained use of mercury, from the lytta
vesicatoria, from minute and occasional doses of arsenic, from the free
exhibition of sarsaparilla, and from generous diet, porter, and wine.
It is however, altogether impossible to lay down fixed rules for the
management of sores; every one has some peculiarity in its nature and
appearance, every one requires some peculiarity in the applications
and mode of dressing, and what may suit well one day will often prove
inert or injurious on the succeeding. Again, when any one application
or internal remedy is found to agree with the sore, it ought not
to be changed for fashion’s sake, from caprice or routine. In this
department of surgery, one practitioner excels another, not by his
superior knowledge of the various applications, but by his acuteness
in selecting the remedy adapted to the particular state of the sore,
and in accommodating the various ointments, lotions, or powders, to the
different characters which the ulcer assumes during its progress. The
healing of sores is very easy in some constitutions, and very difficult
in others. Hence, it has been supposed that the long existence of a
sore is a salutary process of nature, tending to relieve or prevent
some more serious affection, and on this account some are little
solicitous to procure its cicatrisation, or at least are careful that
the cure shall not be a speedy one. If, indeed, an extensive sore,
or a series of sores, be suddenly dried up, the circumstance must be
considered as very unfortunate, and the consequences may even be fatal;
but such an occurrence is unusual, and the patient may in general be
saved by the timely insertion of an issue in the neighbourhood of
the sore, or by an active employment of what is best calculated to
insure a renewed discharge. Some sores have a disposition to extend
by sloughing, and such frequently attack the lips and pudenda of
weakly children; they are also met with, amongst the lowest class of
prostitutes, in the cleft of the nates, in the groin, &c., and in such
cases the sore closely resembles hospital gangrene.
OF HOSPITAL OR CONTAGIOUS GANGRENE, AND SLOUGHING PHAGÆDENA.
This disease has been long known, and has proved very fatal in crowded
and badly-aired hospitals. It may break out at any season, but hot,
sultry, and damp weather is most favourable to it. No breach of
surface, however small, is secure from its attack. The wound becomes
painful and swollen, and loses its healthy, florid appearance; the
granulations are flabby, and appear as if distended with air; vesicles
form, containing serum or a bloody fluid; the pain is stinging; the
secretions are suspended; and the wound is either altogether dry,
or covered with slimy, tenacious, and peculiarly offensive matter.
An ichorous discharge follows, the pain increases. The sore assumes
a circular form, and its edges are everted; erysipelas attacks the
surrounding integuments, often extending over the whole limb, and
forming a principal feature of the disease. In fact, violent erysipelas
and hospital gangrene are affections very closely allied to each other,
often arising at the same time, and from the same causes. Both are
accompanied with great constitutional disturbance; but in erysipelas,
this generally precedes, whilst in hospital gangrene, it follows, the
appearance of the malady. The lymphatic glands, in the neighbourhood of
the gangrenous part, inflame and suppurate, the skin gives way, and the
gangrene soon seizes the newly-formed sore. Fever supervenes, the pulse
is often full and strong, and the surface hot; there is great nausea
and thirst; the tongue is brown, and the bowels much disordered. The
inflammation and ichorous discharge increase. A thick slough covers the
sore, and its fetor is peculiar and intolerable. The burning pain is
excruciating. Blood oozes out, and, in the last stage, the hemorrhage
is often copious from large vessels exposed by the ravages of the
disease.
Now, extensive mortification occurs, the strength fails, the pulse
becomes tremulous and indistinct, the features collapse, the surface
is bedewed with a cold sweat, diarrhœa and hiccough come on, and death
puts an end to the patient’s suffering. Such is the progress of the
disease in those who were previously in perfect health. Often, however,
it is attended with typhoid symptoms almost from the beginning, in
people whose constitutions are wasted, who have long laboured under
disease, or who have been long confined in hospital. The important
distinction between these cases must influence the treatment; what
succeeds in the one will destroy in the other. It is not the name of
the disease which is to be combated, but each symptom as soon as it
presents itself.
Those who have been once afflicted with hospital gangrene are extremely
liable to its recurrence, and that too on the same sore; though the
secondary disease is much less acute. This form has been termed
Sloughing Phagædena, and may seize a sore not previously affected with
gangrene. The wound, recovering from the first attack, and appearing to
heal rapidly, with good discharge and healthy surface, presents, near
its edge, a small dark spot or ulceration, of the size of a small bead
or shot, of a circular form, with a ragged edge, excavated surface, and
fetid discharge. Several such points may appear; they spread rapidly,
unite, and the surface is soon destroyed. It is not uncommon to find
one part of the sore of a healthy appearance, and even cicatrising,
whilst in another part the surface is rapidly disappearing. The
patient complains of a burning sensation in the part; suppuration
occurs round the edges and beneath the slough, and the dead parts
separate; but the same process again takes place, and another slough
forms. The malady proceeds often with a rapid and alarming pace; the
sloughs are soft, pulpy, and reddish, and separate one after another,
exposing muscles, nerves, bloodvessels, and bones. Joints are opened
into, and the vessels, having been exposed, perhaps for a day or
two, give way, and fatal hemorrhage ensues, their cavities not being
obstructed with coagula as in sphacelus. The patient is sick, has no
appetite, and labours under other symptoms of deranged stomach; there
is restlessness, with a small quick pulse, and all the symptoms of a
weakened and sinking system. The ulceration becomes more rapid, the
discharge is bloody and peculiarly offensive; all the symptoms increase
in violence, and may proceed for fifteen or twenty days, or terminate
in four or five, either in convalescence or death.
Hospital gangrene is supposed to arise from a variety of causes:
from the state of the atmosphere, moist and hot—from inattention
to cleanliness, the parts around the sore being seldom wiped, the
matter collecting amongst the dressings, and becoming acrid by
putrescence—from irritating applications, as rancid ointments—from
a too stimulating diet, and from the abuse of wine and spirits—from
mechanical irritation, in moving the wounded over rough roads and in
bad conveyances, as after great engagements—from specific contagion
without immediate contact. After being once generated, it is
propagated by direct communication, by the application of morbific
matter from sponges, dressings, or instruments. It is not easy to say
how the disease originates.
In the treatment of this scourge, great attention must be paid to
cleanliness in all circumstances. Free ventilation must be constantly
preserved in the apartments of the sick, and fumigations assiduously
employed. The infected ought to be separated from the others, and but
few patients placed in the same ward. Stagnant drains and accumulations
of filth out of doors are to be removed; otherwise, during hot weather,
the atmosphere becomes much vitiated. Care must be taken, also, to
destroy all the dressings which have been used; not to employ sponges,
but to wipe the surface in the neighbourhood of the sore occasionally
with tow, which is to be burnt immediately, being an article of little
value, and easily procured. Too much attention cannot be paid to
the cleaning of those instruments with which gangrenous sores have
been treated, before they be applied to healthy wounds. As to the
constitutional treatment, the alimentary canal must first be purged
of its solid contents, and the secretions afterwards kept in as good
a condition as possible. When the wound or sore is surrounded with
intense inflammation, and when the skin is dry and the pulse strong
and full, with all the other symptoms of an inflammatory diathesis,
immediate recourse must be had to free abstraction of blood from the
system, as thus only can the progress of the disease be efficiently
arrested; and if inflammatory symptoms exist, when there is reason to
expect the occurrence of the disease, though no symptom of it has yet
appeared, then, too, venesection combined with purgatives is demanded,
as being the most powerful preventives. Emetics are also recommended.
When the affection is from its commencement accompanied with typhoid
symptoms, depleting measures must do irreparable mischief: in such
cases, the local pain and irritation will be relieved by the exhibition
of opium or camphor, and it may also be of service to preserve a
perspirable state of the surface by means of Dover’s powder, or other
diaphoretics. Preparations of Peruvian bark, the decoction with or
without the tincture and acid, or the sulphate of quina, are often
given with great advantage—opium is also usefully exhibited. Vinegar,
weak acids, the nitric and muriatic acids diluted, have been used as
external applications, and nitrate of silver, the red oxide of mercury,
and the actual cautery, have been applied with the view of removing the
diseased parts, and procuring a healthy surface. Arsenic in solution,
used so as to produce a slough, followed by hot dressings, has been
supposed to be serviceable. A much safer and more powerful application
is the strong nitric acid, which sometimes requires to be applied over
the diseased surface very freely, and repeated if need be.
THE MALIGNANT PUSTULE
Is a gangrenous inflammation of the skin, rarely extending to the
subcutaneous cellular tissue, and in this respect differs from
carbuncle, which commences and is seated in the cellular texture. It
arises from the application of the fluids of animals which have died
of putrid diseases common in some marshy and low situations. It is
communicated not only by matter from the diseased part, but also by
the blood of the animal; thus it is frequently observed in those who
handle the recent skin or flesh; and the excrements also appear to be
possessed of the poisonous principle. It spreads from one person to
another by contact. There is much reason to doubt, whether carrion
introduced into the stomach produces this disease, though by some it
is maintained that even the respiration of effluvia from putrescent
substances produces malignant fever, with fetid evacuations and
gangrenous patches on the skin. In the West of Scotland, an instance
occurred some years ago, in which several persons lost their lives
from eating the flesh of dead animals which had been washed ashore.
The occurrence of malignant pustule is rare in this country. Some time
since, I met with a well-marked case in a shoemaker, who had been
employed in killing some sickly pigs. Whilst turning over and removing
the abdominal viscera of one of them, he had scratched his finger
slightly with a pin stuck in his jacket, and he then perceived that
the contact of some putrid matter from the intestines caused great
pain. On the third or fourth day afterwards, he presented himself with
a malignant pustule formed on the hand between the fore and middle
fingers. The pain was very intense, and the disease seemed to be fast
extending. Active treatment was employed, and the patient had a speedy
recovery.