Part 10

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.

DISSERTATION III.

_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.