Chapter V: Part 5

[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.

The true phagedena seems always to confine its action to a particular spot[76]; but many of these diseases, which have been described under the same name, appear to be capable of inducing a general action, similar to the venereal disease, affecting different parts of the body in succession. A case of this kind is related by Mr. Adams, in his Observations on Morbid Poisons: A gentleman who had a small pustule on the prepuce, squeezed it so as to make it burst, and soon afterwards had connection with a woman whom he had long known. The sore remaining without healing, he applied a solution of caustic, and had recourse to mercurial frictions. But, notwithstanding these, the ulcer spread, and soon reached the scrotum. The mercury was now laid aside, and bark, with a good diet, were substituted, after which the ulcer put on a healing appearance; but, before cicatrization took place, a feverish fit supervened, with violent pain in the part. In the course of a short time, however, the unfavourable symptoms disappeared, and a healthy condition was again apparently induced. These paroxysms of fever, and subsequent amendment, alternated with each other for a considerable time, and each relapse was preceded by a livid appearance round the sore. These appearances at last went off, and the sore assumed more the aspect of the true phagedena. The cicatrizing process now began at the upper part, and proceeded rapidly until almost the whole sore was covered. But, nearly about this time, copper coloured spots appeared on the hands, and the inside of the right thigh; and, in a day or two afterwards, an ulcer appeared in the throat, with “bumps” on the head. Shortly afterwards a node appeared on the tibia, and the patient became bandy. The blotches speedily began to ulcerate, and another appeared on the sternum. Mercury was now given freely, and at first with apparent success, for the ulcers looked better, and no new affection appeared; but, whenever the mercurial action was beginning to be fully induced, the granulating appearance of the surface was destroyed, and it became of a dusky colour, discharging “bloody sanies.” The bones remained stationary. The medicine was now discontinued, and the patient went to the country; but, on his return, in about a fortnight, “his throat was again ulcerated[77]. Such of the old external ulcers as had not healed, threw up a kind of fungus granulations.” The sore on the penis, which never had been completely well, had spread to the size of a shilling, but had no phagedenic, or specific appearance. Mercury was afterwards tried, and some bones exfoliated from the nose. The ulcer healed; but, as soon as he recovered from the effects of the mercury, new blotches and ulcerations, with a new enlargement of the tibia, took place. “He is now under his fifth mercurial course.”

[76] The neighbouring glands sometimes swell and suppurate, but they heal kindly, and the disease proceeds no farther.

[77] From this, it would appear, that his throat had been at one time healed.

In this case, mercury evidently was prejudicial, except toward the end. It does not appear that the caustic had been freely applied to the original local disease, which might have destroyed it. These affections, which were by some considered as venereal, evidently differed from that disease, in the rapidity of its progress, in the appearance of the primary sore, and in the history of the whole of the symptoms. We are as yet in the dark with regard to a specific remedy for these, and similar affections.

There are several other ulcers, which appear upon the penis after coition, which probably depend upon the application of a peculiar contagion. These[78] are sometimes superficial and phagedenic; they spread fast, and heal rapidly, frequently in the course of a night after precipitate has been applied. At other times they are deeper, and more like a little cup; the surface is smooth and glossy, without any appearance of granulations; the discharge is thin, and the base and margin quite soft. The best remedy is the caustic, with the subsequent application, precipitate, or ung. hyd. nit. dilut. When buboes form, I have always found them heal without the use of mercury. If, however, the bubo be the first symptom which appears, as is sometimes the case, (for the morbid agent is occasionally absorbed before it excites action in the part to which it is applied), then it is generally much more difficult to heal than when it is preceded by a local action, and induced by the absorption of matter generated there.

[78] Many of these have been confounded with the venereal disease, and treated accordingly.

It were much to be desired that they should be accurately described, and one kind distinguished from another, for there are probably many different species.

If these local, or primary symptoms, be not speedily removed, a general disease is induced, as we see in the case already mentioned, and as is proved by numberless other instances. These general affections are marked by ulcerations of different parts; and the ulcers have a different appearance, according to the nature of the morbid agent. In some cases they are better and worse at intervals. Mercury has, in almost all these cases, been used; but, although some are ameliorated by it, yet others resist its action. At first, indeed, they generally appear to heal; for the mercurial action, when forming, interrupts the progress of the former diseased action; but, whenever the mercurial action is fully induced, we sometimes find that the appearances change, and the progress generally becomes quicker than formerly[79].

[79] Some actions cannot be induced during the continuance of others. Other actions can, in these circumstances, be formed, and displace completely the former action. A third set seem to give a modification to the original disease: They change it to a certain degree; but the change is not salutary, and they never displace it. The mercurial action, when induced during the existence of some of the diseases which I am describing, comes under the last, or third class. At first, during the formation of the mercurial action, the former diseased action is interrupted, in the same way as the natural action is injured during the period of formation of other actions, when no peculiar disease previously existed. On this account, the sore assumes a better appearance; and, if the action be nearly terminating naturally (as some actions do, and as the primary action in these diseases more readily does than the secondary), it quickly heals up; but, if this be not the case, the appearances soon change, and the disease becomes much worse.

There is a disease which is not unfrequently confounded with syphilis, but which is distinct from it; I mean small ulcers about the mouths of children, which are more like aphthæ than any thing else; but, soon after their appearance, small blotches appear in the body, which become first raised into a little flat vesicle, and then ulcerate superficially. These ulcers have a watery appearance, not much unlike tetters; but the appearance of the vesication, and dark colour of the preceding blotches, prevent any confusion. Nurses who suckle these children have generally small calyciform ulcers on the nipples, of a pale colour, and discharging a thin watery matter. I have had no opportunity of ascertaining what constitutional symptoms would be produced by the continuance of the disease in the nurse, as I have generally found that the application of diluted citrine ointment to the nipple produced a cure, without any internal medicine. The constitutional symptoms in the children were cured by the same local applications, with small doses of calomel internally[80].

[80] There are some cases, described by different authors, of affections of the nipples and breasts, in which the ulcers appear to have been chiefly of the phagedenic kind.

I have likewise observed ulcers on the lips, throat, and mouth, which at first had a very doubtful appearance; but they evidently are distinct from syphilis, and belong to the suppurating sores. When superficial, the buff-coloured matter, or inorganised substance which covers them, has a fibrous, or thready appearance, the margins are slightly tumid, and of a florid, or kind of pink colour. The application of caustic, or burnt alum, is often sufficient of itself to cure these; but small doses of mercury sometimes accelerate the cure. At other times these sores penetrate deeper, and affect the bones. The surface, which is deep, is covered with a thick yellow slough, like an overacting ulcer. The margins are tumid, ragged, and of a light, or pink colour. Sometimes the disease spreads along the gum, which becomes soft, ulcerated, and separates from the teeth, which very frequently become black, and, when the sockets are affected, drop out. I have not had an opportunity of observing these sores go the length of inducing constitutional symptoms. It is not easy to ascertain the cause of these sores; sometimes they succeed the use of mercury; but, at other times, it is impossible to blame any evident agent. The transplanting of teeth sometimes has been the mean of inducing sores similar to these; and, in these cases, the disease has generally passed for syphilis[81]. But although the venereal disease may have been inoculated in this manner, it is certain, from the appearance of the ulcers, from their rapid progress, and from the sudden effect produced by a very small quantity of mercury, that the disease, which is commonly induced by transplanting teeth, is not syphilitic.

[81] Cases of this kind may be found in Mr. Hunter’s Treatise on the Venereal Disease, and in the third volume of the Medical Transactions.

Sibbens is another disease which has been very frequently confounded with syphilis, and is by many considered to be only a variety of that disease; but they evidently are different, as appears from the mode of infection, and the properties of the contagion[82], the appearance of the ulcers, their progress, and certain circumstances in their cure, particularly their requiring less mercury than venereal ulcers in the same state, and from their yielding readily to preparations of mercury, which do not accomplish a cure of syphilis.

[82] This disease is communicated even by drinking out of the same vessel with an infected person, even although that person have no sores on the lips, but only in the throat. The contagion then must either be dissolved in the saliva, or remain very powerful, even when reduced to a state of halitus.

This disease appears first on the part which is most directly acted on by the contagion. This part becomes red and inflamed, having an erysipelatous appearance. Ulceration quickly takes place on a particular spot, and spreads rapidly along the whole inflamed part. The disease then advances more slowly; the erysipelatous appearance spreads around the margin of the ulcer, and ulceration follows upon the inflammation. In the course of some time (the precise period is not fixed), the skin becomes affected with blotches, or sometimes clusters of small pustules, the intervening space betwixt each being affected with an erysipelatous inflammation. These spots soon ulcerate, and the surface rises up into a fungous, which is irregular, and has an aspect somewhat betwixt the look of the venereal sore and a very bad scrophulous ulcer. The bones next become affected, particularly at the articulating surfaces, which swell, and become carious. It is said that the secondary ulcers in general appear first upon the genitals; but, of all those whom I have examined, no affection of these parts had taken place, from which I would infer, that the disease has no peculiar tendency to affect these in preference to other parts. It is likewise said that the disease sometimes disappears from one part, whilst it breaks out in another; but this also I have never witnessed. The primary ulcers also have no tendency, like some others, to change their appearance, and become milder, or heal by continuance, but spread, destroying the nose, orbits of the eyes, and face. The constitution seems to suffer much more from this disease than from syphilis, in the same length of time; for the patient soon assumes a pale sallow look; and hectic comes on much sooner than in syphilis.

The cure of this disease is effected by washing the sores with solution of corrosive sublimate, or dressing them with precipitate ointment, at the same time that we use mercury internally, without which no escharotic, or local application whatever will effect a cure. In general, less mercury cures this disease than syphilis; and it is worthy of remark, that permanent cures may be obtained by the hyd. mur. corros. which is not the case with syphilis. When the bones are affected, we must, in conjunction with the specific remedy, use such applications as the state of the bone, considered as a simple affection, will require.

The cynanche maligna, and scarlatina, are also diseases producing ulceration in the throat. The sores are of the suppurating kind, a thick lymphatic-looking, or inorganised substance being thrown out, instead of organic particles, or granulations. This, in the former disease, very soon becomes black, and putrefies; but the slough so formed differs materially from that caused by gangrene; for, in this disease, unless in the very last stages, there are no real gangrenous sloughs. It is unnecessary here to make any particular observations on these diseases.

Herpes[83] is a disease which is very frequent, and often prevents large ulcers from healing, as these come to assume the action of herpetic ulcers, although, from their magnitude and depth, they do not put on the same appearance as when the disease is confined to the skin. The large ulcers are of a dark sloughy appearance, discharge thin matter, are painful, and are surrounded with herpetic ulcers, and scabs in the skin. This is a very frequent disease on the legs, and is very tedious. Bathing with warm sulphureous water is often of service, at the same time that we dress the parts in the intervals with camphorated ointment. Citrine ointment is also very useful; but the following liquor is one of the best, and most effectual applications:

[83] There are many different divisions of herpes; as, for instance, into the scurfy, scabby, miliary, &c.; but, for a description of these, I must refer to the writers on the diseases of the skin.

R. Pulv. Calcis Vivi Recen. unciam.
Flor. Sulph. semiunciam.
Aq. Font. sesquilibram. Coque ad dimidiam dein cola.

This ought to be applied with cloths to the parts.

When, by these means, the disease of the skin, and the specific action of the ulcer is removed, pressure is often of service in completing the cure.

There is a specific ulcer, which is met with most frequently on the legs, and which is very troublesome. The skin becomes in several points inflamed, or of a dark red colour. These parts speedily ulcerate, and the sores belong to the suppurating kind, for no distinct granulations, or organic particles, are formed; but the surface is smooth and glossy, and the discharge thin and copious. These sores are generally pretty deep, in proportion to their extent, or of a cup-like appearance. They not unfrequently occur in scrophulous habits. Mercury, exhibited in small doses internally, appears to be useful. Precipitate, as a local application, generally answers very well; but, when the sores become irritable, or spread under this treatment, hemlock poultices succeed better.

There is a small ulcer, which sometimes is met with on the foot, of an irregular shape, fiery appearance, and surrounded with thick jagged margins, which, in particular parts, are white, and callous. The neighbouring integuments are of a dark red colour. The discharge is thin, and the pain considerable. Caustic, and afterwards the application of the adhesive plaster, are the best local applications. Internally, the use of hemlock is sometimes of service.

It occasionally happens, that, nearly about the same time, most of the patients in a ward of an hospital shall have their ulcers rendered unhealthy. They become foul, dark coloured, and spread: The discharge is thin, and the pain is greater than formerly. The application of cloths dipped in gastric juice is sometimes of service in these sores, and is one of the best remedies; but, not unfrequently, the patient must be removed to a different situation before a cure can be obtained.

Having made these detached remarks on some specific ulcers, I shall, in the succeeding dissertations, consider, at greater length, others, which are, in the general estimation, considered as more dangerous and alarming.

DISSERTATION IV.

_On the Spongoid Inflammation._

The disease which I am now going to consider, has either not been described at all by any author, or has, when it was noticed, been considered as of a cancerous nature. It is perhaps one of the most alarming diseases to which we are subjected; because, as yet, we know of no specific remedy; and an operation can only be useful at a time when it is very difficult to persuade the patient to submit to it.

I have named it the spongoid inflammation, from that spongy elastic feel which peculiarly characterises the disease, and which continues even after ulceration takes place.

This disease begins with a small colourless tumor, which, if there be no thick covering over it, such as the fascia of a muscle, or the aponeurosis of the foot, is soft and elastic, but tense if otherwise. It is at first free from uneasiness; but, by degrees, a sharp acute pain darts occasionally through it, more and more frequently, until the sensation becomes continued. For a considerable time, the tumor is smooth and even, but afterwards it projects irregularly in one or more points; and the skin at this place becomes of a livid red colour, and feels thinner. It here readily yields to pressure, but instantly bounds up again. Small openings now form in these projections, through which is discharged a thin bloody matter. Almost immediately after these tumors burst, a small fungus protrudes, like a papilla, and this rapidly increases, both in breadth and heighth, and has exactly the appearance of a carcinomatous fungus, and frequently bleeds profusely. The matter is thin, and exceedingly fœtid, and the pain becomes of the smarting kind. The integuments, for a little around these ulcers, are red, and tender. After ulceration takes place, the neighbouring glands swell, and assume exactly the spongy qualities of the primary tumor. If the patient still survive the disease in its present advanced progress, similar tumors form in other parts of the body, and the patient dies hectic.

On examining the affected parts after death or amputation, the tumor itself is found to consist of a soft substance, somewhat like the brain, of a greyish colour, and greasy appearance, with thin membranous-looking divisions running thro’ it, and cells, or abscesses, in different places, containing a thin bloody matter, occasionally in very considerable quantity. There does not seem uniformly to be any entire cyst surrounding the tumor, for it very frequently dives down betwixt the muscles, or down to the bone, to which it often appears to adhere. The neighbouring muscles are of a pale colour, and lose their fibrous appearance, becoming more like liver than muscle. The bones are uniformly caries, when in the vicinity of these tumors. If large, they are found rough, and broken off into fragments; if small, they are generally soft and porous. This tumor is sometimes caused by external violence; but often it appears without any evident cause.

I know of no remedy which has a power of checking the progress of the complaint, or removing it. Friction, with anodyne balsams, sometimes gives relief in the early stages; but it does not seem to retard the progress of the disease. Extirpation is the only remedy which has a prospect of being successful; but it is only adviseable in the early stages, whilst the disease is entirely local, and has not extended to the neighbouring glands; for, after they become affected, the chance of recovery is greatly diminished. It is, however, sometimes difficult to persuade patients at this time to submit to amputation, or extirpation, because the pain and inconveniences are inconsiderable; but the operation ought to be urged with all the eagerness which a conviction of its absolute necessity, and its precarious issue, if delayed, will inspire.

After making these observations, I shall illustrate the subject with the following cases, the first of which is intended to show the difficulty of extirpating the disease, when the operation is delayed after the first appearance of the tumor. In the second, we see the destruction which the bones suffer by it, and the extent of parts which it may affect. The third gives us an instance of the affection of the glands: And the fourth, of the most advanced stage, or that in which distant parts have suffered. The last is an instance of the good effects of an early operation.

CASE I.

William Stirling, without any very evident cause, perceived a small tumor on the top of the shoulder, about midway betwixt the termination of the neck and the articulation of the humerus. This gradually increased for some months, and by the time when I saw him was larger than a goose’s egg: It was spongy and elastic, and attended occasionally with pain.

Although the duration of the tumor was an unfavourable circumstance, yet I undertook the operation. I made an incision through the whole length of the skin, and dissected it off the tumor, (the upper part of which was covered with a coat, or cyst), down to its base; but, when I now began to separate it from the parts below, I found that it had no defined bottom, but penetrated down betwixt the muscles, which were soft, pale, and had lost their fibrous structure. I therefore cut off the tumor close by the muscles, and then separating them with the back of the scalpel, I removed with the finger as much of the tumor as I could observe. Several arteries sprung; but these were pretty readily tied, although the vessels were very tender. A troublesome oozing, however, took place from many points of the diseased muscles. This was moderated by applying the sponge dipped in cold water, after which the skin was laid down, and its lips brought close together.

On dressing the patient on the third day after the operation, the skin was found not to have united; but its lips were red and inflamed. In this state it continued for several days, when the part began to grow tumid, and discharge a thin fœtid matter. The skin then retracted still more, and a fungus protruded, which gradually increased; but it was smooth and regular, and of a pale colour, so that it rather had the appearance of a superficial ulcer, raised up by a tumor from below, than the ulcerated surface of a diseased substance itself. In this state it continued for two or three months, when irregular projections appeared on the ulcerated surface of the new tumor. These soon burst, and a fungus protruded, of a carcinomatous appearance, and bleeding very frequently and profusely. Swellings of the axillary glands succeeded this, and the patient became much enfeebled, and evidently hectic. As I have not heard of him for several weeks, I suppose that he has died.

In this case a second tumor succeeded to the first, owing to the impossibility of extirpating the whole, and this exactly resembled the original one, except in having its surface covered from its commencement with an ulcer; but this ulcer was not the specific one of the spongoid inflammation.

CASE II.

John Overend was attacked with pain in the right thigh and loins, which were considered as rheumatic. Shortly after the thigh was observed to be elongated, and issues were applied over the hip joint, upon the supposition of its being a common case of morbus coxarius. But no considerable relief was obtained by this; on the contrary, the upper part of the thigh swelled, whilst the lower part wasted, his appetite diminished, his pulse was quickened, and he passed sleepless nights. The thigh was rubbed with anodyne balsam, and draughts with laudanum were given every night, but only with temporary benefit. For the course of some months these complaints continued, with occasional remission and aggravation. At last he began to complain of difficulty in making water; and this soon ended in a complete retention. The catheter was attempted to be passed; but although its point was bent, and directed so as to correspond to any deviation of the prostate gland from its right situation, it could not be introduced. By examining per anum, a large elastic tumor could be felt in the pelvis, which was considered as the bladder. A trocar was therefore passed up the rectum, and the bladder attempted to be tapped. A considerable quantity of bloody fluid came away; but he complained of no pain at the glans, which most patients do when the bladder is wounded; and a considerable quantity of high coloured fœtid urine was voided by the urethra, and continued even afterwards to be passed, although with some difficulty. Within a week after this the patient died.

On dissection, I found the hip joint to be completely surrounded with a soft matter, resembling the brain, inclosed in thin cells, and here and there cells full of thin bloody water; the head of the femoral bone was quite carious, as was also the acetabulum. The muscles were quite pale, and almost like boiled liver, having lost completely their fibrous appearance, and muscular properties. On opening the abdominal cavity, the same kind of substance was found within the pelvis; and the greatest part of the inside of the bones of the affected side were quite carious. Large cells were found in this diseased substance, containing bloody water; and it was into one of these that the trocar had entered when the bladder was attempted to be tapped.

CASE III.

James Walker received a stroke upon the outside of the foot, immediately below the ankle joint. A small tumor instantly formed, which continued stationary for several weeks, and gave him little uneasiness; but afterwards it began to increase, and was attended with a shooting pain. The tumor was elastic, pretty tense, and rather irregular in its appearance. I was anxious to operate, but the man would not give his consent. I therefore advised frictions with anodyne balsam, which at first gave him relief, but soon lost its effect. For several weeks I heard nothing of him; but, at the end of this time, he again applied to me. The irregularities of the tumor were much greater, more prominent, of a red colour, and one of them had burst: From this a soft half-organised fungus protruded, and a bloody fluid run out constantly. An operation was again urged, but the timidity of the patient made him again refuse. A month after this he came under the management of another surgeon. There were now three openings in the tumor, from each of which protruded a broad cauliflower-looking fungus, covered with thick fœtid matter; there was likewise a thin red serum discharged from the margins of the ulcers. The tumor was as large as a child’s head, and one of the inguinal glands was a little swelled. The man now consented to lose his limb, and amputation was accordingly performed. Whenever the turniquet was applied, a very copious stream of veinous blood issued from the tumor; but this ceased when the veins had emptied themselves. Unluckily it was considered as unnecessary to extirpate the diseased gland.

On examining the leg, all the bones of the ankle joint were found to be quite soft and carious; the tumor consisted of a soft substance, resembling the brain, with light membranous intersections. The cyst on the upper part was hard and thick, but beneath it was entirely wanting, having either never been formed betwixt the tumor and the tendons of the muscle, or having been destroyed. The former opinion is the most probable; for I have never in any stage found the cyst continued over the under or back part of the tumor, but it always terminated imperfectly in the part on which the tumor was seated.

The wound healed as well as could be desired, but the gland became rather larger, notwithstanding which no operation was urged. Two months after this I was requested to visit him. The gland was now as large as the head of a newborn child; it was soft and spongy, and had at one part an irregular prominence, but the skin was not coloured. The pulse was about one hundred and thirty, and the patient completely hectic. In this situation I proposed nothing excepting nourishment. He died in the course of a week after I saw him.

CASE IV.

The following case shows this disease in its most advanced stage. It is extracted from the fifth volume of the London Medical Journal, and is intituled, “An Account of the Fatal Effects produced by attempting to remove a Ganglion by Seton.” It was drawn up by Mr. W. Dease, surgeon in Dublin.

“In July 1781, a clergyman, aged thirty-seven, consulted me about a moveable ganglion, of the size of a small nutmeg, situated between the fore-finger and thumb of his right hand, near the wrist. He was eager to have it removed, and had been advised, for this purpose, to have a seton passed through it, as the best and most certain method; but, as he was apparently a robust healthy man, and the ganglion was attended with no pain, I advised him to consider it as a matter of no consequence, and not to meddle with it. Four months after this I was desired to visit him, and found him in a melancholy situation. A seton had been passed through the ganglion, and the consequences were, that the back of his hand had inflamed violently, that the ganglion had rapidly and amazingly increased, and that the openings made by the seton were filled with an ill-conditioned fungus, which sprung up as fast as it was removed, and was attended with frequent hemorrhage, and much pain. In consultation, it was agreed to remove this fungus by a free incision, which was done, and the metacarpal bones appeared bare and rough. Another opening was made through the thenar, and a seton passed through it, in order more effectually to prevent the growth of fungus. The bark was administered in large quantities, an opiate was given at night, and due attention was paid to the regimen of the patient. This method seemed to promise the most happy event. The fungus appeared to be entirely destroyed, a laudable suppuration took place, the swelling of the hand subsided, and the sores in a short time were so contracted as to indicate their speedy cicatrization. These favourable appearances, however, were not of long continuance; for, after some time, the fungus began gradually to rise again, and any mode of keeping it down, either by caustic, cutting, or pressure, seemed to produce no permanent good effect, as it increased rapidly, and at length degenerated into the most frightful cancerous fungus I have ever seen. Every local application that has been recommended in similar cases was tried in this, but without success; and internal remedies proved equally inefficacious. He took, for a considerable length of time, two ounces of bark in substance, in the course of twenty-four hours, so that he took, in the whole, twenty-eight pounds of that medicine. The extract of hemlock had also a fair trial, but produced no apparent effect.

“When he had laboured under this complaint fifteen months, he was advised to undergo the amputation of his hand; but before he would consent to submit to this operation, he chose to have an account of his case transmitted to the Royal Academy of Surgery at Paris, that he might have their opinion of it: The result of which was, that the members of the academy pronounced the fungus not cancerous, but merely scorbutic. This decision, by the bye, should make us extremely cautious in delivering our sentiments on similar occasions, without seeing the patient, as much depends on the general appearance of the sores in cases of this sort. The academy were of opinion, that the disease was entirely local, and required only local treatment. For this purpose, they advised that the fungus should be taken down by means of euphorbium, savine, &c. and afterwards washed with salt water. If this method proved ineffectual, recourse was to be had to the actual cautery, from the application of which they seemed to expect the most decisive advantages. To this mode of treatment the unhappy sufferer submitted; and, during the space of six weeks, the fungus was almost every day burnt down with the actual cautery; but his complaint all the while continued to gain ground apace; so that being now disappointed in all his expectations of relief from regular practitioners, he had recourse to quacks of every denomination. The arsenic plaster of Plunket was applied, and he was salivated for seven weeks. At length, after undergoing the operation of a variety of nostrums, he again placed himself under my care. In consultation, it was much doubted whether amputation should now be thought of, as the patient seemed to be in the last stage of a cancerous consumption. His limbs were swelled, and his whole habit was wasted by the repeated hemorrhage from the fungus, which was now so increased in bulk as to weigh down his arm, and entirely cover the back of his hand. In short, after every return of hemorrhage, it was apprehended that the next would put a period to his sufferings.