Part 20

We shall next treat briefly of gunshot wounds; under this head are included the contused and the lacerated, caused by splinters, &c. The vitality of the injured surface is generally destroyed at once, whence bleeding seldom occurs, even after whole limbs have been shot away; in some cases, however, hemorrhage is profuse, as when a large artery has been wounded by small shot. The effects on the system are extremely various; some persons are affected with tremors, anxiety, and depression from slight wounds; while the most severe injuries are often unaccompanied by any disturbance of the nerves. The shock is generally of short duration, disappearing soon, on the patient’s being reassured and encouraged, or after his taking a little wine or opium. In gunshot wounds, those inflicted from a distance or close at hand can in general be readily distinguished. In the latter, the wound is large and lacerated, portions of the wadding are impacted, and the skin around is marked with grains of gunpowder. In the former, the wound is small and clean. When a ball passes through a fleshy part, the opening at its entrance is small and depressed; whilst that by which it escaped is open, with everted edges. When it follows a superficial course, its track is marked by a wheal, or elevation of the skin with discoloration. At one time, it was believed that the most serious consequences resulted from a ball passing close past the body without even touching it—that in this way violent concussion of the brain, proving instantly fatal, was produced; but this notion has been disproved by experience; part of the head accoutrements, of the hair, of the nose, and of the ears, have been shot away by cannon-balls, and yet no disturbance of the brain has followed either immediately or consecutively. The opinion originated from the circumstance of soldiers having been found dead without any evidence of injury; but bones are often broken and comminuted by an indirect blow, or by a spent ball, without any breach of surface or external sign remaining; internal injuries indeed—rupture of viscera—more than sufficient to cause instant death, are thus inflicted without any apparent external læsion.

The course of a ball in the body is often very strange, depending on the force with which it is projected, or the resistance which is opposed to it, and on the position of the struck part. Balls often pass under the integument almost completely round the head or chest, having first struck the bone at a very oblique angle. Frequently they remain, lodged along with part of the clothing which they thrust before them. In such cases, they may be immediately removed, their exact situation being previously ascertained by external examination, or by means of a probe. They can generally be extracted through the aperture by which they entered; but if situated superficially, and at a distance from the opening, this will be more readily accomplished through an incision made upon them; if allowed to remain, suppuration will occur in the neighbourhood, the surrounding cellular tissue will be condensed, an abscess will be formed containing the foreign body, and by the process of absorption proceeding in the parts external to the abscess, the ball will at last reach the surface, and be discharged. The track is often so extremely tortuous, as to render it impossible to ascertain the situation, or even the existence of the foreign body, which greatly impedes the operation; and, in other instances, it may be necessary to allow the ball to remain undisturbed, on account of its being placed near important parts, which might be injured by any attempt at removal. Foreign bodies often remain lodged in fleshy or membranous parts for years, having become enveloped in a dense cyst, and having ceased to produce any great irritation. In consequence of the force with which they have been projected, and the resistance which has been opposed to their progress in the body, musket-balls, when extracted, either immediately after the infliction of the injury, or after a considerable time has elapsed, are seldom found to retain their globular form, but are flattened and ragged, and not unfrequently completely divided by the bones on which they have impinged. A bullet may be divided into numerous fragments on a bone, and part may enter into the osseous substance, whilst other portions penetrate in all directions into the soft parts, and, though sharp and irregular, may remain long in the dense cellular cyst which forms over them, without producing pain or inconvenience. There will necessarily be suppuration, and generally discharge of dead matter, from gunshot wounds, in consequence of the bruising of the parts by the ball, which may be expected to injure the superficial layer of parts in its tract so severely, that it must slough more or less.

Besides, the bones are often splintered by the force with which they are struck, and loose portions of them lodge amongst the muscles; then they are the cause of much mischief, for, on account of their long, sharp, and irregular form, they occasion great irritation, suppuration ensues in various parts, sinuses form, and the cure is rendered very tedious. In other cases, the bone is split in a longitudinal direction, and, in the cylindrical bones, these fissures are often of great extent.

Considering the nature of the body which inflicts the injury in a gunshot wound, and the velocity with which it is impelled, it is evident that the cure must be in all cases tedious, in consequence of the sloughing and suppuration which is induced, particularly at the aperture through which the ball passed. The foreign body ought always to be removed as early as possible, provided it can be accomplished without much violence, or injury to the parts. Dilatation of gunshot wounds is now had recourse to only to facilitate the removal of balls, splinters, &c., and even with this view, it ought to be employed but to a very slight extent, if at all; for foreign substances, when deeply seated, can be much more easily taken out when the sloughs are separating, and the parts relaxed by suppuration; then, too, they can be more readily reached through a counter-opening, when their situation renders this expedient. In short, the surgeon is not justified in cutting for balls, unless they are easily felt, and not deeply lodged. In order to discover the foreign body, probes will sometimes be required; the finger often answers the purpose best, unless when the wound is of considerable depth. If, on examination, the ball cannot be discovered, and if there is reason to think that it has followed an indirect course, the surgeon will, sometimes, be assisted in his search by placing the patient in that position in which he received the wound, and then judging of the circumstances most likely to affect the foreign body in its passage. In many cases, extraction can be accomplished by means of the finger alone; in others, forceps and scoops, various in length and size, are indispensable. Afterwards, light dressings are to be employed; and in the first instance, cold applications may prove advantageous in keeping down the inflammatory action; but when inflammation has commenced, and to encourage suppuration, warm fomentations and poultices are to be preferred; they will in many cases be both more grateful to the patient and more beneficial in their results, when used even from the commencement. Afterwards, it will be necessary to afford sufficient support to the parts by bandaging, and to change the applications according to the particular circumstances:—soothing, if the wound be irritable, stimulating, if inert, and gently escharotic, if the granulations be exuberant.

In severe injuries of the limbs, the surgeon must be guided by the state of the part, and of the constitution, by the circumstances in which he is placed, as to accommodation, and mode of transportation, &c., in deciding on the removal of the part by amputation,—or on making an attempt to save it, by trusting to, and assisting, the processes of nature. The question whether to amputate immediately, and on the spot, merely allowing the shock, if any exist, to pass away, or to delay till suppuration occur, is now scarcely a matter of dispute. When it is evident, from the extent, violence, and nature of the injury, that there is danger of speedy mortification, or of extensive and severe inflammation and suppuration, amputation is to be instantly performed,—delay is inadmissible. In comminution of the hard, with contusion and laceration of the soft parts—where limbs have been shattered and completely detached, or nearly so—in lacerations of parts, including the principal bloodvessels and nerves—fractures of the heads of bones, with openings into the joints—and in bad compound fractures, more especially of the thigh (for all compound fractures of the upper part of the thigh are dangerous), amputate at once. When the limb has been retained, and gangrene arises in consequence of the external injury, and when there is no reason to suppose that any internal cause is also in existence; or when the violence of inflammatory action has subsided, and the patient is become hectic, with profuse purulent discharge, and with disunited bones, then amputate. But, in this latter case, the chance of recovery is not so great, and the proportion of recoveries small; whereas, in the immediate or primary operations, the very reverse holds true. Such is the experience of the greater number of military surgeons. In civil practice, the results are somewhat different; a greater proportion of primary amputations are unsuccessful, and the secondary turn out more favourably than the statements of military surgeons would lead one to believe. In all cases, the judgment of the surgeon must guide him in his determination. The circumstances of the case, and the probable contingencies, must be all duly considered, and he must not proceed with his knife where there exists even a slight chance of preserving the limb.

Paralysis occasionally follows wounds of the arm, forearm, face, &c., inflicted by accident or operation, and this arises from an important nerve, or set of nerves, being divided. In cases of simple division, without much separation of the parts, reunion of the nerves may take place, and their functions be restored. If the limb remains paralysed, after cicatrisation of the wound, tepid effusions, friction, dry or with liniment, stimulating applications, &c., may sometimes be advantageously employed.

TETANUS

Is a disease which occasionally follows a wound, but rarely in this country. It is a spasmodic contraction, with rigidity, of the voluntary muscles, in some cases involving the whole body, in others the upper part of it only, and in some it is confined to a certain class of muscles. When the extensors are affected, the disease is termed opisthotonos; when the flexors, emprosthotonos. Complete tetanus is said to exist when the flexor and extensor muscles exactly balance each other, and the body is thereby kept straight and rigid. But when the affection is confined to the muscles of deglutition, and chiefly to those moving the lower jaw, it is called trismus. The disease has besides been divided into acute and chronic, and into traumatic and idiopathic; the one following wounds, the other arising from internal causes, or circumstances not connected with the læsion of the surface. The disease supervenes at various periods; sometimes, though rarely, not long after the infliction of the injury, in other instances after the lapse of eight or ten days, and often when the wound is healing, or nearly cicatrized. In warm climates, where it is of very frequent occurrence, it occasionally seems to be caused by exposure to damp and changeable weather; in children, it supervenes on the slightest irritation. It is often induced by the presence of splinters, or rather bodies of an irritating nature, and by the partial division of nerves. Not unfrequently it occurs after clean wounds, as amputation or venesection; in the former it may perhaps arise from a nerve being included in the same ligature with an artery, in the latter, from a nervous twig being partially divided. The more prominent symptoms are, stiffness of the back of the neck, and contraction of the features; difficult deglutition supervenes, and the efforts to accomplish it are attended with violent spasms of the muscles of the pharynx and œsophagus. Spasms of the injured limb often precede those of the muscular system generally; the muscles of the lower jaw become rigid and spasmodically contracted, and by a continuance and increase of the spasmodic action, the mouth is at last completely and immovably shut. The muscles of the trunk and limbs become affected, and there are violent spasms of particular sets of them, most generally of those situated posteriorly; thus the body is bent violently backward, so that its whole weight is supported on two points only, the heels and the occiput. These symptoms are not constant; relaxation occurs, and the patient enjoys a cessation of the malady: but this is only temporary; the painful feelings and the spasms soon return. A symptom of the most distressing nature is pain and spasmodic twitching of the diaphragm, impeding respiration, and imparting a shock to the whole system. Occasionally, emprosthotonos occurs, but, so far as my experience goes, the body is much more frequently bent backward; the muscles are sometimes ruptured by the violence of their own action. The circulating system and sensorial functions are often not much disturbed; but during the whole course of the disease, the bowels are much constipated. In most cases of traumatic tetanus, after four or five days, all the symptoms become aggravated; the countenance is horribly distorted, the spasms of the diaphragm are more frequent and violent, and the patient dies convulsed. Sometimes, though rarely, the fatal termination does not take place till the eighteenth or twentieth day. On dissection, the pharynx is found contracted, and bearing marks of acute inflammation. In one case, which fell under my observation, there was ultimately great difficulty in breathing and expectorating; and on examination, the trachea, as well as the pharynx, bore evident marks of inflammation, and were filled with a viscid mucus. In some instances, there are evident marks of inflammation of the spinal chord; the vessels, more especially at the lower part, are found enlarged, tortuous, and engorged with blood; portions of lymph are seen deposited on the arachnoid covering, and a serous fluid is effused, not unfrequently mixed with blood. Such appearances, however, are not observed in every case of fatal tetanus, and therefore it cannot be asserted as a fact, that the disease is dependent on a morbid condition of the spinal chord, though in certain cases the two affections coexist. By some it has been supposed, that in consequence of the distended and engorged state of the spinal arteries, the origins of the nerves are stimulated, and that a morbid affection of them ensues, giving rise to the tetanic symptoms; but want of uniformity in the morbid appearances prevents such a cause from being generally set down as the origin of tetanus.

This disease is one of the most intractable with which the surgeon has to contend. In the acute form, time is scarcely allowed for remedies; and in the advanced stage, it is with much difficulty that medicine can be received internally. Of course all irritations must be removed, both local and general, as far as that can be accomplished. If the patient be robust, and if the tetanic symptoms be ushered in with arterial incitement, general depletion ought certainly to be practised; and if the symptoms be such as to render the propriety of general bleeding dubious, blood may be abstracted locally, from the back of the head, or along the spine; and this may be followed by such counter-irritants as act rapidly. At the same time, powerful purgatives must be given, so as to bring the bowels into a better state; for, as already observed, obstinate constipation is a constant attendant on this disease. But the most important indication is to alleviate and prevent, if possible, the spasms; and for this purpose, opium is to be administered in large doses, either by itself, or combined with camphor or other antispasmodics. By such means, the disease has in some cases been arrested, but in the majority it has proceeded unabated. Some practitioners recommend and employ cold affusion and immersion, whilst others prefer the warm bath; and the latter appears to be the safer application, though neither can be considered as efficacious. Great relief and benefit seem to have accrued from the frequently repeated use of a warm bath, with some drachms of the tart. antimonii dissolved in it. I have had only two opportunities of trying this practice; one a chronic ease, where, after the division of the nerves proceeding from the wound, this remedy, with others, seemed to allay the spasms in a very remarkable manner: the patient recovered. In the other, a very acute case, after the extraction of a splinter from betwixt the thumb and forefinger, the bath was tried; the patient felt much comforted by it; but suddenly expired in a violent convulsion, whilst being replaced in bed. Great relaxation follows this remedy, profuse perspiration, and subsidence of the rigidity and convulsive action of the muscles. The practice was recommended to my notice by my excellent friend Dr. Stevens, Professor of Surgery at New York. In some cases, it would be worth trial to produce instant vesication by the acetic solution of cantharides or ammonia, and then try the effect of the application to the blistered surface of some of the alkaloids, such as morphia, aconitine, &c., or belladonna might be applied.

Some practitioners have used mercurial frictions along the spine, or on other parts of the surface; while others administer stimulants, and enemata with tobacco and turpentine. When there is reason to apprehend that the symptoms arise in consequence of laceration or partial division of a nervous trunk, it has been recommended to complete the division of it; and the practice is worthy of adoption, as in some cases it appears to have been successful. Little good can result from scarification of the wound. Amputation of the wounded member has also been proposed, particularly in chronic cases, and in one or two it has succeeded. I have made trial of it in but one instance, and in that it failed. Acute tetanus had followed a lacerated wound betwixt the thumb and forefinger; amputation of the forearm was performed, and immediately after the operation the spasms abated; but they soon returned, notwithstanding the free use of opium, and other remedies, and the patient died. In this case, the branch of the median nerve was found partially divided, and its cut extremities were thickened and inflamed. During the operation, I wished to abstract a considerable quantity of blood, but the arteries seemed to be so spasmodically contracted, as to permit the flow of a small quantity only. On examination after death, the median nerve was of its natural appearance, excepting at the bend of the arm, where it was of a bright-red colour. No change could be perceived in the brain or spinal chord, though the examination was conducted with the utmost care.

OF ULCERS.

By ulcer is generally understood a breach of continuity in the soft parts of the body, with secretion of purulent or other fluid. But as suppuration may be independent of ulceration, so may we occasionally see a loss of substance like an ulcer on the surface of parts, without the production of pus, or any other morbid secretion, of which some instances are noted in the remarks on Atrophy of Articular Cartilage. Mr. Burns, in his excellent volume on the Principles of Surgery, has extended the term to the reparative process, as well as the destructive; this, if adopted, would lead to confusion and misapprehension.

Ulcers vary much in disposition and appearance, follow wounds, abscesses, sloughing, eruptions, &c., and often occur without any previous læsion of the surface. Those most generally met with are comprehended in the following classes:—1. The simple purulent ulcer, or healthy or healing sore. 2. The weak or sluggish ulcer,—a sore with undermined integuments and an unhealthy state of the cellular tissue. 3. The indolent ulcer,—a sore with hard elevated edges, and presenting little or no appearance of reparation. 4. The irritable ulcer,—a sore with over-action, and generally affecting only the mere surface of the true skin. Besides these, there are sores connected with diseases of the bones, and others arising from specific action; some are complicated with a varicose state of the veins: the former have been already treated of; the latter are reserved for consideration. Ulcers change their characters, as from simple to irritable, and from indolent to inflamed; the change depends on situation, on the state of the constitution, and on the treatment which they receive.

I. The appearances of the first class were described when the healing of wounds by granulations was considered, p. 173. They heal more readily on the upper extremities, on the face, neck, and trunk, than on the lower limbs; for in the former parts the circulation is more vigorous, the natural processes of cure proceed more easily, and are less liable to interruption. The sore only requires rest, a clean condition of the surrounding parts, mild and light dressings, and moderate support; dry lint or lotions are preferable to ointments, since the latter are apt to irritate by their rancidity. When the sore is of considerable size, and there is a tendency in the granulations to rise above the level of the surrounding skin or cicatrix, the edges may be protected by very narrow slips of fine old linen or cambric, spread with fresh spermaceti ointment or cold cream; a pledget of dry lint is then laid on, and retained by a roller. The dressings thus arranged do not adhere, and the tender cicatrix is not ruffled and disturbed; or a piece of pierced linen spread thinly with unirritating ointment may be placed over the sore, and above that dry lint. When the sore has contracted to a small size, and some powder, as starch or calamine stone, or a piece of dry lint, may be applied, so as to allow a scab to form for the protection of the subjacent surface; but this will, in most cases, be better accomplished by touching the surface lightly with lunar caustic or blue stone; the fluids on the part are thereby immediately coagulated, a crust is quickly formed, and by covering it with charpie, it is retained in its situation, whilst the process of cicatrisation proceeds beneath it: if a small quantity of matter should be secreted, it readily escapes by the sides of the crust, without disturbing either it or its covering; the limb should be raised above the level of the trunk. Sores on the lower limbs are always difficult to manage. The reparative process is tedious, on account of their situation; the parts are at a distance from the centre of circulation, their action is weak, the return of blood is tardy, and the same facility is not afforded of restraining the motions of the part as in the upper extremities. In persons of a good constitution, however, the simple purulent sore often heals speedily, even in the lower limbs. Before cicatrisation can take place, it is essential that the granulating surface should be on a level with the sound surface around; this soon takes place when a favourable position is observed, and the part is kept at rest; but by neglect, the new matter is often absorbed. Again, the healing process cannot advance where the granulations are exuberant, large, and flabby, and have risen above the proper level: they must be kept in check by due compression, and by astringent lotions, containing salts of zinc, copper, &c. The constant meddling with sores, the touching them with this, that, or the other caustic, is much to be reprobated. Should it be necessary to destroy granulations, and bring them down to the surrounding surface, one good rubbing with the blue stone will generally suffice. If the ulcer is large, the granulations close to the cicatrix should only be destroyed, leaving the centre to be dealt with as the cure advances.

During the cure, the patient must be a good deal confined to the recumbent posture; when erect, a bandage or laced stocking must be applied to the limb; thus the return of blood is assisted, swelling is prevented, and the affected parts placed in a state of comparative rest. Much pressure ought to be avoided, as it is apt to produce bad effects upon the sore, causing absorption of the granulations, thin bloody discharge, and great tenderness of the surface. After cicatrisation, the scars may be absorbed, and sores reproduced, by external injuries, or an unhealthy state of the body; and so much does the state of a sore depend upon that of the general health, that the one is a good index of the other.

II. In the second class of sores, or those with weak action, the granulations are flabby, of a pale colour, and possessed of little sensibility or vascularity; the discharge is gleety, and the surface is liable to be destroyed by ulceration or sloughing, upon the slightest excitement of the circulation in the part. The surrounding integuments are generally of a bluish colour, in consequence of their separation from the subjacent parts; and in several places of the neighbourhood, small, unhealthy, detached abscesses may exist; at some points of the sore, glairy fluid is seen to ooze out on pressure, and a probe can be passed pretty deeply into the cavity of an abscess in the soft parts beneath. These sores may arise from an unhealthy condition of the cellular tissue, taking place spontaneously, or following slight injury; they are attributable to the state of the constitution, and may result from an ulcer, originally of a healthy character, which has remained long open, in consequence of its great size, or other impediments to its contraction.

It is the business of the surgeon, in cases of this description, first to obtain a sound foundation, by destroying the unhealthy skin and cellular tissue; the free application of caustic potass will answer this end most readily and effectually. Its application is attended with considerable pain, but the practice is more successful and less severe than the removal of the unsound parts by the knife or other means. The small abscesses may be all freely laid open; the diseased cellular tissue may be cut into, or cut away; in short, incisions may be made in all directions, and in every portion of the affected part; but still it will be found that the granulations, as they appear, become pale and flabby, that they spring from a loose and powerless base; matter will again collect; the surrounding skin will again be undermined; no progress will be made towards soundness. But by attention to the state of the constitution, and the application of potass, the neighbouring sound parts have their actions roused, and the healing is carried on rapidly. After its application, a poultice may be applied for a few days, and followed by water dressing, and then stimulants, both internally and externally employed according to circumstances, the parts being all along well supported. The long continued use of warm fomentations, or poultices, is prejudicial, as tending to diminish still farther the action of the parts; ointments can be of little service, and will generally do harm.

III. Indolent ulcers, which have long existed, are frequently met with on the lower limbs. Their margins are thick and insensible—their surfaces smooth, hollow, and of a pale colour—the discharge is scanty, and adheres to the surface. A sore, having been long open and neglected, degenerates into this state. Poultices are to be applied for a day or two, to clean the surface, promote the discharge, and soften the callous margins. This is the more necessary, if, as is often the case, the sore, or the surrounding integuments, are inflamed when the patient applies for relief. Afterwards, the applications must be of such a nature as to moderate the discharge and keep the granulations firm and healthy. In such cases only is adhesive plaster applicable, and in them it produces the most beneficial results. Supposing the ulcer to be situated on the fore and middle part of the leg, a bandage should first be firmly applied from the toes to a little below the sore; the ulcerated part of the limb is then encircled by narrow strips of adhesive plaster, tightly drawn, and with the extremities of each strip crossing immediately over the ulcer. A pledget of tow is placed on the plasters to absorb the discharge, and the bandage is brought over dressings, and continued for some way upward. By this application, the margins of the sore, it is supposed, are brought nearer to each other, and the ulcerated surface diminished; the sluggish granulations and the subjacent parts are stimulated, and a more vigorous action being excited, the process of reparation proceeds speedily and effectually; the surrounding parts, previously turgid and œdematous, are by the pressure brought to the same level with the newly-secreted matter, and new skin is quickly formed. In the previous state of matters, the old skin was much elevated, and an action was in progress, causing a continuance of that elevation; by the compression, the whole limb is properly supported, serous effusion prevented, absorption excited, and œdema removed; the livid swelling of the lower part of the limb, which might arise from the tightness of the adhesive plaster, is obviated by the bandage being first applied. A feeling of uneasiness in the limb sometimes follows such dressing, but is of short duration; should it increase, so as to amount to pain, the elevation of the limb and the pouring of cold water occasionally over the dressings will soon restore the parts to comfort. Or the adhesive plaster may be slit up behind, immediately after its application; indentation of the limb being thereby avoided, and sufficient pressure at the same time kept up on the sore. If possible, the dressings ought not to be removed before the second day, as much irritation will be produced by their frequent renewal. The benefits arising from this mode of treatment are truly surprising; the slow and indolent ulcer is speedily converted into the simple purulent sore; the white and recent cutaneous substance encircles small pointed and florid granulations, which bleed from the slightest rudeness of touch; and the space formerly occupied by an unsightly sore is soon diminished to a small and firm cicatrix. It is only necessary to continue this mode of dressing so long as the granulating surface is below the level of the surrounding surface. Then the object being attained, the deranged state of the cellular tissue being got rid of, and the ulcer put in a state favourable for cicatrisation, the sulphate of zinc lotion not over strong may be resorted to; positive rest and support of the affected part being still enjoined and observed. In the old and debilitated, however, in whom the indolent sore most frequently occurs, the integuments remain purple and shining, and from very slight causes the cicatrix is absorbed, and breach of surface is reproduced.

These sores are often connected with a varicose state of the veins. In all such cases, a degree of compression on the affected limb must be maintained, both during the continuance of the sore, and after it has healed. The usual situation of such sores is on the leg, and the varicose state of the veins does not, in general, extend above the knee; in such cases, a radical cure may be attained (provided the patient wishes to encounter the attendant risks, rather than submit to a continuance of the disease) by effecting an obliteration of the saphena major vein. The manner of doing this, and its effects, were mentioned while treating of diseased veins. In some cases, the saphena minor is also varicose to some extent, the varices on which must also be obliterated. Sometimes as many as eight or ten needles must be applied, in pairs, before the circulation of a limb can be brought into a right state.

IV. In this fourth class of sores, or the irritable from over-action, the sore and its edges are of a jagged, irregular appearance, the discharge is thin and bloody, and considerable pain is experienced. This ulcer is very superficial, involving only the surface of the corium and the more sensible part of the integument, the papillæ, and extremities of the nervous filaments. They often succeed to scaly eruptions, and present a remarkable character and appearance, cicatrising in the centre, whilst they extend towards the circumference. The sore is often covered by an ash-coloured slough; on the removal of which, granulations arise, but these either again slough, or are removed rapidly by the ulcerative process. In the treatment of such sores, complete rest and soothing applications are the means on which most reliance is to be placed. Warm and soft poultices, such as those of arrow-root, fomentations, tepid water dressing, solutions of opium, or of extract of poppy, and the occasional use of a local vapour bath to the part, may be enumerated amongst the means best fitted to allay the irritable condition of the ulcer. When the surrounding integuments are swollen, red, painful, in short, evince marks of inflammatory action going on in them, the feelings of the patient will be rendered grateful, and the cure advanced, by abstraction of blood from the parts by punctures. When the nature of the sore is changed, and when cicatrisation has commenced, the treatment is similar to that of a simple granulating surface—light dressings, due support of the parts, and repression of exuberant granulations by the sulphate of copper. The nitrate of silver, applied in substance round and about the ragged edges, is of great service at an earlier period. This practice must be sparingly and seldom resorted to, but it does wonders when judiciously employed.

Ulcers are occasionally prevented from healing by the presence of dead portions of tendon, fascia, or cellular tissue, and are accompanied in general with a bad state of constitution; in such it is necessary to clean the surface by a powerful escharotic, and the best is potass. Otherwise, granulations will be produced quickly, it is true, and in abundance, to supply the original substance; but then they are flabby and exuberant, new skin is formed slowly, if at all, and the sore does not contract; but by removing the dead or half-dead surface, a healthy and firm foundation is prepared, on which is securely and gradually raised the new matter for cicatrisation. But caustics are applied injudiciously to firm and healthy granulations which have not yet reached the level of the surrounding parts; they are only useful in repressing exuberant granulations, or in destroying half-dead parts, which interrupt or deteriorate the cure: and when employed, it should be effectually, and once for all.

Along with the topical treatment of ulcers, internal means are, in most cases, indispensable. Thus, in indolent ulcers, the state of the constitution is often sluggish, and ought to be changed by the exhibition of alteratives or stimulants; with this view, much benefit is derived from a prudent and restrained use of mercury, from the lytta vesicatoria, from minute and occasional doses of arsenic, from the free exhibition of sarsaparilla, and from generous diet, porter, and wine. It is however, altogether impossible to lay down fixed rules for the management of sores; every one has some peculiarity in its nature and appearance, every one requires some peculiarity in the applications and mode of dressing, and what may suit well one day will often prove inert or injurious on the succeeding. Again, when any one application or internal remedy is found to agree with the sore, it ought not to be changed for fashion’s sake, from caprice or routine. In this department of surgery, one practitioner excels another, not by his superior knowledge of the various applications, but by his acuteness in selecting the remedy adapted to the particular state of the sore, and in accommodating the various ointments, lotions, or powders, to the different characters which the ulcer assumes during its progress. The healing of sores is very easy in some constitutions, and very difficult in others. Hence, it has been supposed that the long existence of a sore is a salutary process of nature, tending to relieve or prevent some more serious affection, and on this account some are little solicitous to procure its cicatrisation, or at least are careful that the cure shall not be a speedy one. If, indeed, an extensive sore, or a series of sores, be suddenly dried up, the circumstance must be considered as very unfortunate, and the consequences may even be fatal; but such an occurrence is unusual, and the patient may in general be saved by the timely insertion of an issue in the neighbourhood of the sore, or by an active employment of what is best calculated to insure a renewed discharge. Some sores have a disposition to extend by sloughing, and such frequently attack the lips and pudenda of weakly children; they are also met with, amongst the lowest class of prostitutes, in the cleft of the nates, in the groin, &c., and in such cases the sore closely resembles hospital gangrene.

OF HOSPITAL OR CONTAGIOUS GANGRENE, AND SLOUGHING PHAGÆDENA.

This disease has been long known, and has proved very fatal in crowded and badly-aired hospitals. It may break out at any season, but hot, sultry, and damp weather is most favourable to it. No breach of surface, however small, is secure from its attack. The wound becomes painful and swollen, and loses its healthy, florid appearance; the granulations are flabby, and appear as if distended with air; vesicles form, containing serum or a bloody fluid; the pain is stinging; the secretions are suspended; and the wound is either altogether dry, or covered with slimy, tenacious, and peculiarly offensive matter. An ichorous discharge follows, the pain increases. The sore assumes a circular form, and its edges are everted; erysipelas attacks the surrounding integuments, often extending over the whole limb, and forming a principal feature of the disease. In fact, violent erysipelas and hospital gangrene are affections very closely allied to each other, often arising at the same time, and from the same causes. Both are accompanied with great constitutional disturbance; but in erysipelas, this generally precedes, whilst in hospital gangrene, it follows, the appearance of the malady. The lymphatic glands, in the neighbourhood of the gangrenous part, inflame and suppurate, the skin gives way, and the gangrene soon seizes the newly-formed sore. Fever supervenes, the pulse is often full and strong, and the surface hot; there is great nausea and thirst; the tongue is brown, and the bowels much disordered. The inflammation and ichorous discharge increase. A thick slough covers the sore, and its fetor is peculiar and intolerable. The burning pain is excruciating. Blood oozes out, and, in the last stage, the hemorrhage is often copious from large vessels exposed by the ravages of the disease.

Now, extensive mortification occurs, the strength fails, the pulse becomes tremulous and indistinct, the features collapse, the surface is bedewed with a cold sweat, diarrhœa and hiccough come on, and death puts an end to the patient’s suffering. Such is the progress of the disease in those who were previously in perfect health. Often, however, it is attended with typhoid symptoms almost from the beginning, in people whose constitutions are wasted, who have long laboured under disease, or who have been long confined in hospital. The important distinction between these cases must influence the treatment; what succeeds in the one will destroy in the other. It is not the name of the disease which is to be combated, but each symptom as soon as it presents itself.

Those who have been once afflicted with hospital gangrene are extremely liable to its recurrence, and that too on the same sore; though the secondary disease is much less acute. This form has been termed Sloughing Phagædena, and may seize a sore not previously affected with gangrene. The wound, recovering from the first attack, and appearing to heal rapidly, with good discharge and healthy surface, presents, near its edge, a small dark spot or ulceration, of the size of a small bead or shot, of a circular form, with a ragged edge, excavated surface, and fetid discharge. Several such points may appear; they spread rapidly, unite, and the surface is soon destroyed. It is not uncommon to find one part of the sore of a healthy appearance, and even cicatrising, whilst in another part the surface is rapidly disappearing. The patient complains of a burning sensation in the part; suppuration occurs round the edges and beneath the slough, and the dead parts separate; but the same process again takes place, and another slough forms. The malady proceeds often with a rapid and alarming pace; the sloughs are soft, pulpy, and reddish, and separate one after another, exposing muscles, nerves, bloodvessels, and bones. Joints are opened into, and the vessels, having been exposed, perhaps for a day or two, give way, and fatal hemorrhage ensues, their cavities not being obstructed with coagula as in sphacelus. The patient is sick, has no appetite, and labours under other symptoms of deranged stomach; there is restlessness, with a small quick pulse, and all the symptoms of a weakened and sinking system. The ulceration becomes more rapid, the discharge is bloody and peculiarly offensive; all the symptoms increase in violence, and may proceed for fifteen or twenty days, or terminate in four or five, either in convalescence or death.

Hospital gangrene is supposed to arise from a variety of causes: from the state of the atmosphere, moist and hot—from inattention to cleanliness, the parts around the sore being seldom wiped, the matter collecting amongst the dressings, and becoming acrid by putrescence—from irritating applications, as rancid ointments—from a too stimulating diet, and from the abuse of wine and spirits—from mechanical irritation, in moving the wounded over rough roads and in bad conveyances, as after great engagements—from specific contagion without immediate contact. After being once generated, it is propagated by direct communication, by the application of morbific matter from sponges, dressings, or instruments. It is not easy to say how the disease originates.

In the treatment of this scourge, great attention must be paid to cleanliness in all circumstances. Free ventilation must be constantly preserved in the apartments of the sick, and fumigations assiduously employed. The infected ought to be separated from the others, and but few patients placed in the same ward. Stagnant drains and accumulations of filth out of doors are to be removed; otherwise, during hot weather, the atmosphere becomes much vitiated. Care must be taken, also, to destroy all the dressings which have been used; not to employ sponges, but to wipe the surface in the neighbourhood of the sore occasionally with tow, which is to be burnt immediately, being an article of little value, and easily procured. Too much attention cannot be paid to the cleaning of those instruments with which gangrenous sores have been treated, before they be applied to healthy wounds. As to the constitutional treatment, the alimentary canal must first be purged of its solid contents, and the secretions afterwards kept in as good a condition as possible. When the wound or sore is surrounded with intense inflammation, and when the skin is dry and the pulse strong and full, with all the other symptoms of an inflammatory diathesis, immediate recourse must be had to free abstraction of blood from the system, as thus only can the progress of the disease be efficiently arrested; and if inflammatory symptoms exist, when there is reason to expect the occurrence of the disease, though no symptom of it has yet appeared, then, too, venesection combined with purgatives is demanded, as being the most powerful preventives. Emetics are also recommended. When the affection is from its commencement accompanied with typhoid symptoms, depleting measures must do irreparable mischief: in such cases, the local pain and irritation will be relieved by the exhibition of opium or camphor, and it may also be of service to preserve a perspirable state of the surface by means of Dover’s powder, or other diaphoretics. Preparations of Peruvian bark, the decoction with or without the tincture and acid, or the sulphate of quina, are often given with great advantage—opium is also usefully exhibited. Vinegar, weak acids, the nitric and muriatic acids diluted, have been used as external applications, and nitrate of silver, the red oxide of mercury, and the actual cautery, have been applied with the view of removing the diseased parts, and procuring a healthy surface. Arsenic in solution, used so as to produce a slough, followed by hot dressings, has been supposed to be serviceable. A much safer and more powerful application is the strong nitric acid, which sometimes requires to be applied over the diseased surface very freely, and repeated if need be.