Part 13

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 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.

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.

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. It is now indeed almost universally laid aside, owing, in a great measure, to the observations of the ingenious Mr. Pott.

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.