Chapter IV: Part 4

The second variety is only to be cured by removing the caries bone; but the same remedies which are used in the first variety may be employed here, as palliatives, or the means of preventing the ulcer from becoming worse. By a continuance of these applications, in cases of slight caries, a cure may, after some time, be obtained; for the thin layer of diseased bone, either comes away in fragments through an opening in the ulcer[62], or it is sometimes absorbed. This last event, the absorption of the bone, is particularly induced by pressure, applied by means of the adhesive plaster; and, therefore, where the disease is not extensive, it is always proper to have recourse to this; but if, upon trial, we find it to fail, or to convert the sore into the second species of this genus, which it sometimes does, we must omit it.

[62] In the description of this variety, it was mentioned, that there frequently was a small opening in the surface, which communicated with the bone; but, even where this is not the case, the layer of dead bone, when it exfoliates, comes through the granulations; for the granulations of the sound bone below raise it up, in consequence of which, pressure is made from within outward upon the ulcer, by which absorption is produced at that part, in a greater degree than deposition; and, therefore, a vacuity is produced.

As it is only in slight cases of caries that absorption of the bone is to be expected, we may consider it as necessary, in general, as a preparatory step toward healing, that the diseased portion of the bone be separated, and come away externally. It is therefore of advantage to endeavour to accelerate this; because, whatever does so, hastens the cure. Our attempts, with this view, are made at two different stages, and with different intentions. First, when the bone has separated, or exfoliated from the part below, by making an incision through the ulcerated surface, we remove the dead part, and allow the sore to heal. This stage may be discovered, by pushing a probe through the opening, if there be one, or through the granulations, down to the layer of bone, which we find to be elastic when we press on it. But, even although the incision be made before this stage has taken place, no harm is done, because it is of use in the first stage. Second, when the carious bone has not yet exfoliated, but remains in contact with the rest of the bone, ulceration of the sound part not having yet taken place, it will be useful to make an incision down to the bone, and, as soon as the bleeding stops, or lessens, to apply caustic freely, in the whole course of the incision, so as to act upon the caries, or rough portion; or we may use the trephine, or other remedies, which have been formerly mentioned. It sometimes happens, that the soft parts are, at particular portions, and often to a considerable extent, removed by absorption, and the bone, at these parts, is left bare. In this case, no incision is necessary, except occasionally through some bands of granulations which extend across the bare bone; and, therefore, we can at once apply our remedies to the bone, or make perforation with the trephine.

The second species requires to be treated differently, according to its varieties.

As the incipient stage of the first variety frequently consists of only one short paroxysm, it would often be unnecessary to have recourse to any peculiar treatment; but, as it is impossible, a priori, to say whether the state of evacuation is to continue, it is requisite, in every instance, to vary our treatment, and apply the proper remedies for the disease.

Poultices are frequently useful in this kind of ulcer, when the surface is dark coloured, and the integuments are not yet affected. They have sometimes an effect of checking the morbid state, if this be not already done; but they more generally promote the absorption of the morbid granulations, after which the surface becomes healthy. If, however, the action be still greater, and more permanent, then the ulcer is tending toward the confirmed, or perfect state of overaction, and poultices are not of equal service; they are even sometimes hurtful.

Gentle pressure, accompanied with the use of cold water, is of service in the same cases in which poultices are employed; that is to say, when the action has not become perfect, but has rather begun to subside, and the granulations remain dark coloured, and in a dying state. They are absorbed, and replaced with more perfect and healthy granulations.

When, however, the action still continues in the same state of overacting, or seems to be increasing, these remedies are rather hurtful; and we will derive more benefit from using applications of a gentle stimulating nature, which restore the action to a more perfect and natural state, in the same way as they cure the inflammatio debilis. For this purpose, one of the best applications is the following:

R. Opii drachmas duas.
Camphoræ scrupulum.
Vini Albi uncias quatuor. Macera per triduum, dein cola.

This may be applied by means or a bit of lint to the sore. It generally produces considerable smarting for a few minute, after which the pain abates. The application is to be repeated every hour, or every two hours, until the sore begins to look healthy, and the pain abates. The adhesive plaster ought then to be substituted in its place.

Laudanum may also be employed with the same intention, but it is inferior to the other.

Lemon juice is also sometimes useful, and may be employed where the opiated wine fails, or is not at hand.

When the state of overaction becomes confirmed, and progressive, the sore spreads, becomes very painful, and assumes the appearances which have been already described. In this case, the application of carrot, or turnip poultices, is frequently useful. These vegetables are sometimes made into a poultice by boiling them, and, at other times, by rasping them down raw.

Camomile flowers, boiled in milk, and then expressed, yield a decoction, which, when made into a poultice with crumb of bread, frequently abates the pain. Sometimes the application of cloths, dipped in fine oil, give relief.

These sores are also frequently reduced to a more healthy state, by applying cloths dipped in the following mixture:

R. Ammon. Hepatizatæ[63] guttas decem.
Aq. Font. uncias octo.

[63] The ammonia hepatizata is prepared by passing a stream of hepatic gas through the aqua ammoniæ.

This produces a moderate degree of smarting for a little time, during which the former painful sensation arising from the sore lessens, and does not return for some time. When the peculiar pain of the ulcer again manifests itself, the solution is again to be applied.

An ointment, consisting of two drachms of powdered opium, and one ounce of simple cerate, is also a very useful application.

Sprinkling the sore with red precipitate, or touching the surface with caustic, frequently stops the disease.

The kind of erythematous affection, which frequently affects the surrounding skin, is best removed by stimulating applications, which abate the pain or hot sensation, and make it less apt to ulcerate. The following is a very useful application for this purpose. The affected part is to be lightly dusted with it occasionally:

R. Hyd. Precip. Rub. unc. i.
Pulv. Opii semiunc.
Cretæ Ppt. unc. ii. Tere simul ut fiat pulvis subtiliss.

When, by any of these applications, the state of overaction is overcome, pressure is the best remedy for preserving our ground, and producing a cure; for, remedies which may be useful in the diseased state, will be hurtful when this state is removed.

In this sore, anodynes are to be freely employed internally; for, given sparingly, they do no good[64].

All the applications ought to be made gently, and lightly; because any mechanical irritation increases the disease.

[64] No external application whatever will produce the same good effect, if used by itself, as when such a general action is induced as shall co-operate with the local remedies. In slight cases, thirty drops of laudanum may be given twice a-day; but, when the overaction is more violent, the dose must be more frequently repeated.

The second variety of this species is a very troublesome ulcer, and admits, as has been already observed, of two divisions: First, it not unfrequently happens, that, after an indolent ulcer has been in a healing state for some time, a state of overaction is induced, by fatigue, or other causes, particularly by the natural inability of the newly formed, and not completely perfect granulations, to sustain the action which is necessarily induced in them by their connection with other parts (upon the principle of the communication of action). In this case, the sore becomes foul, dark coloured, and painful, whilst the cicatrix ulcerates, and the new granulations die, so that, in a short time, the ulcer regains its original size, and even spreads slowly to a greater extent. Second, an old ulcer may, without having been previously in a healing state, become converted into the overacting ulcer; because the surface has its power so weakened, that common agents, which naturally excite action in the part, excite a disproportioned and morbid action in the ulcer; but this action is of the low kind, and bears somewhat the same relation to the first species, (or overacting ulcerative action, in ulcers previously healthy,) that the inflammatio debilis does to the inflammatio valida. In this case, the surface is bloody, and the half-formed granulations are of a livid colour; the callus edges are of a dusky red, or modena colour; the integuments are generally mottled; the inferior part of the limb is cold and painful.

In the cure of the first division, we must enjoin rest, as in the second variety of the first species, and apply cloths, dipped in a mixture of two parts of laudanum and one of camphorated spirit of wine, which produces at first considerable smarting; but the sensation is different from the former pain; and, although uneasy, is yet more tolerable than the peculiar pain of the ulcer. This application ought to be renewed two or three times in the course of the day, until the surface becomes of a better appearance, and the pain abates.

The application of the powder of bark to these sores is sometimes, but very seldom, of service[65].

[65] This was probably recommended on account of the sphacelated appearance which these sores sometimes have.

A poultice, formed of decoction of camomile flowers, opium, and charcoal[66], is frequently of use, and should be employed when the laudanum and camphorated spirit fail. This should be applied cold.

[66] Let two ounces of camomile flowers be boiled in three pounds of water down to two. When this is cold, it ought to be strained, and half a drachm of opium diffused in a pound of the decoction. Of this, a sufficient quantity is to be added to powdered charcoal, in order to form a poultice.

In the second division, the fermenting poultice[67] is often of service; but it must, like all other applications, be continued no longer than the state which it was intended to remove remains. If we continue it too long, we do hurt; for, if it be kept on when it produces continued pain, it induces a state of overaction, similar to that which it was intended to destroy. Whenever the surface becomes redder, and the pain less, it may be useful to employ some other application, such as laudanum, &c.

[67] The fermenting poultice is made by adding a spoonful of yest to an oatmeal poultice, and placing it before the fire until it begins to emit air, or rise up in a bubbling way. It is then fit for applying to the sore.

The same observations apply to the use of the gastric juice. Cloths dipped in this sometimes make the overacting surface slough off, and leave the parts below more healthy. The same may be said of the expressed juice of sorrel.

Lime water sometimes operates in the same way.

Red precipitate, mixed with its weight of powdered opium, and half its weight of camphor, may be usefully sprinkled over the surface.

A pound of the recent leaves of hemlock, boiled for half an hour in two pounds of milk, and then expressed, forms an application which sometimes abates the pain, and renders the action more healthy. The juice is to be made into a poultice with crumb of bread.

Decoction of the walnut tree leaves, applied by means of pledgets of linen, or made into a poultice with bran, is occasionally of service.

When, by any of these applications, the morbid state of the ulcer is removed, it is to be dressed according to the genus into which it is then converted.

After these remarks, the treatment of this genus of ulcers may be comprised in the following observations:

First, In the first variety of the first species, or the simple fungous ulcer, the cure is to be attempted by pressure, and gentle stimulants, which render the action more natural, and the granulations, in consequence, more perfect and compact.

Second, In the second variety of this species, we are to employ the same remedies, as palliatives, or as means which may promote the exfoliation of the bone. But, if the disease in the bone be more extensive and tedious, we must cut down through the ulcer, and apply caustic, or mechanical cures, such as perforation, to the caries.

Third, In the incipient stage of the first variety of the second species, we must avoid motion, and all other such causes as tend simply to increase action. When the disease has consisted of one short paroxysm, which has terminated, we must promote the absorption of the diseased granulations, and the process of replacing them with others which are more perfect, which is effected by such remedies as render the action which forms them more natural. This is best done by gentle pressure, and sometimes by poultices. If, however, the paroxysm continue longer, but in a moderate degree, we must use such applications as tend more directly to change the action, and diminish the morbid condition; such as camphorated and opiated preparations, and sometimes the vegetable acids.

Fourth, When this state becomes confirmed and progressive, the action being violent, we must use remedies nearly similar to those which are employed in the last case, and which are useful in the cure of the inflammatio debilis, at the same time that we enjoin rest, and keep the part as easy as possible. In some instances, the action cannot be overcome directly by any application, but is rather increased by them. In this case, we must lay these aside, and use mild and light applications; such as fine oil, fresh cream, &c.; at the same time that we avoid the general causes tending to increase action; such as motion, heat, spirits, &c.

Fifth, When this state occurs in chronic ulcers, we must use such remedies as tend to remove the dead or dying granulations which frequently cover the surface, and such as at the same time produce a more natural action, and restore to the succeeding granulations greater powers and perfection, and a more healthy mode of acting. Stimulating applications frequently have this effect; such as the fermenting poultice, precipitate ointment, &c.; at other times, narcotic applications; such as cicuta, &c. are useful.

Sixth, In these ulcers, the redness and pain of the skin which surrounds the ulcer, is to be treated as the inflammatio assuefacta, by being dusted with the powder which has been already mentioned, or by similar remedies.

Seventh, In all of these ulcers, where the action is violent, much benefit will be derived from inducing the general narcotic action to a considerable extent. Anodynes are therefore to be freely administered, at the same time that we employ the proper local remedies.

Eighth, Whenever the ulcer becomes more healthy, and the action less morbid, the strength of the application is to be diminished; and, when the state of overaction is destroyed, it must be treated as the indolent ulcer, because the granulations are still feeble. Pressure is most useful in this case.

GENUS IV.

_Of the Inflammatory Ulcer._

It sometimes happens, that the ulcerative action becomes converted into the inflammatory; the discharge diminishes, and sometimes ceases; the surface is red; and the edges and surrounding skin are elevated and inflamed. This, which has been called the phlogosis ulceris[68], strictly speaking, does not belong to the division of ulcers, because the ulcerative action is destroyed; but, as it is preceded, and very quickly followed by this action, and as the solution of continuity, and other external appearances continue, this affection may be allowed to rank as a genus amongst ulcers, in conformity to common language.

[68] “Siccitas rubido et phlogosis ulceris facile cognoscuntur; dolore, pruritu, calore stipantur; ca impediunt carnis excrescentiam, adeoque indicant remedia emollientia,” &c. Sauvage Nosol. Meth. Tom. II. p. 613.

When the pain and inflammation are considerable, leeches are frequently applied with utility in the vicinity of the sore; but it is more generally useful to apply warm poultices, which restore the secretory state, and the ulcerative action.

GENUS V.

_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].