Part 12

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, 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.

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.