ON

SIMPLE INFLAMMATION,

And its Consequences.

Of the Cure of Inflammation.

In attempting the cure of inflammation, or its consequences, we must naturally be directed to the means of removal, by the nature of the action itself, and the object which we have in view. The treatment of the inflammatory action may be considered in two points of view; first, as this action consists in peculiar changes of the natural action, which changes we wish to remove; and, secondly, as this action naturally tends to disappear, and produce other actions, which require a peculiar treatment. The observations, therefore, which are to be made upon the method of cure, may be arranged under the heads of the different terminations of inflammation.

Of the Treatment necessary to procure Resolution.

In the treatment of most wounds, our chief intention is to prevent the accession of inflammation, and procure adhesion, which is, in one respect, analogous to resolution. When inflammation has taken place, either in wounds, or in other cases, our great object is, to remove or lessen it as quickly as possible, which we effect, first, by removing the exciting causes of inflammation, or such causes as tend to increase the action; and, secondly, by applying such remedies as tend directly to abate the inflammatory action.

Upon the propriety of removing the exciting causes, and the manner of doing so, very little requires to be said. If any acrid, or stimulating substance, has been applied to the skin, or any extraneous body been forced into it, these must be removed before the inflammation can be resolved; because, if they be allowed to remain, they will keep up the action so long, and to such a degree, that suppuration will be produced, or gangrene, if the part be very sensible, (as, for instance, the cutis) or if the exciting cause be very irritating. Acrid substances are to be removed by ablution with water, which is in general much better than the solutions which are proposed upon the principle of chemically combining with the acrid; because these generally are likewise acrid, or stimulating, and increase still more the inflammation which has taken place, before they can combine with the substance which was formerly applied, and become neutralised. This may be illustrated by the operations of acids and alkalis. If heat have been applied, so as to induce inflammation, we must remove the superabundant quantity of heat, but must not apply cold; because we then do mischief, as will be afterwards mentioned.

When a substance is forced into the skin, so as to stimulate mechanically, we must endeavour to lay hold of it, and pull it out; but if it have penetrated so deep as to make this impracticable, we must then enlarge the wound, and remove it; because we thus may enable the wound to heal by the first intention. If, however, the injury done be great, if the part be much bruised, or the extraneous substances be numerous, we may be less anxious about the extraction of such as require much trouble; because the irritation which is thus given will tend to increase the degree of inflammation, and, very probably, its extent, at the same time, that, from the original injury, there is little prospect of adhesion being procured, or suppuration prevented. We are then chiefly to search after, and extract foreign bodies, when we apprehend that their removal may permit the inflammation to be resolved, and adhesion to take place, and when we expect that their presence will excite a greater action than our endeavours to extract them will do. This is a rule which ought to be carefully remembered by every surgeon, and especially by those whose situation makes them be daily called to take the management of gun-shot wounds. They are not brought to their patient to show how much they can do in the way of cutting and probing; it is their duty to administer relief, and act so as to prevent and abate the inflammatory action, which they will often do most effectually by letting their patient alone, and throwing aside their ball-screws and forceps.

The circumstance of being in an unusual situation, in which the natural action cannot possibly be continued, is also a very frequent cause, producing inflammation, and preventing its resolution. We ought, upon this principle, which has been formerly mentioned, to endeavour, in almost every instance, to bring the sides of the wound together, if an wound has been the exciting cause of inflammation, by which we shall much more readily prevent or overcome the inflammatory action; because we thus bring the parts nearly to their natural situation, with respect to interstice, and thus make the organic particles be more readily thrown out1. This practice ought to be pushed farther than is often done. Even in many contused wounds it will be useful; because, although union may not be immediately produced, yet, when the contused part is either recovered, or absorbed, the inflammatory action may be prevented, or removed, by the restoration of the natural action, if the part be in absolute contact. It must, however, be remembered, that if much difficulty be experienced in bringing and retaining the parts together, owing to the swelling, from the previous existence of the diseased action, then our endeavour will be hurtful; because the irritation which we thus give, has a greater power to increase the action, than the circumstance of the parts being in contact, has to diminish the inflammation, and restore the natural action.

By removing, then, the exciting causes of inflammation, before the action be induced, we shall frequently prevent it altogether from being formed; but, even although we should be disappointed, we, by this removal, render the disease milder, less extensive, and much more easily overcome; for, as long as the exciting causes continue to operate, it is impossible to procure resolution; but the action will be kept up until some other termination, or consequence, be induced. But, although we thus prevent the action from being raised to so great a degree as it otherwise would be, yet we do not immediately overcome or destroy it; because the action, when once induced, has, like every other action, a tendency to continue for some time after its cause is withdrawn. This continuance may be longer or shorter, according to circumstances, and its termination may be more or less unfavourable. We are, therefore, under the necessity of employing such remedies as have a power of directly diminishing or removing this action. It has, however, been doubted, whether they ought, in every instance, to be employed; or, in other words, whether resolution ought uniformly to be desired. It has, for instance, been deemed unsafe to check those inflammations which depended upon a general or constitutional specific disease, or occurred during its existence. But this opinion, which was evidently founded upon the supposition of the operation of morbid humours, cannot be maintained, now that this is given up. Granting inflammation, in every one of these cases, to be dependent upon the general disease, and to exist as a symptom of it, no harm can accrue from resolving it2; because, if the inflammation have once taken place, the full effect of the general disease is produced, which, therefore, cannot be affected by the peculiarity of the termination of this inflammation, unless it be proved, that some humour be sent there to be concocted and thrown out. In many instances, inflammation occurs in a general disease, merely as an accidental circumstance; but, even in those cases where the local inflammation is most decidedly dependent on the general action, and is perhaps essential to it, we find, that no bad effects follow from resolving the inflammation; and, if this be the case with regard to specific inflammation, we may still more certainly extend the principle to the treatment of the simple inflammatory action, with which we have at present a more immediate connection. There are, however, some inflammatory affections which we sometimes cannot put back; such as those tumors which succeed the small-pox; but, when we do succeed, no bad consequence follows; and the failure of some of our attempts can be no argument against the general plan, more than our failure in many other instances.

Resolution is the quickest termination of inflammation, and, therefore, ought, perhaps in every instance, to be attempted, unless in cases where the injury is such that suppuration is unavoidable; as, for instance, extensive bruises, &c. It is our great object, even in those inflammations which we raise intentionally; as, for instance, in the operation for hydrocele. At one time, however, this was not admitted without limitation; and suppuration was, in many instances, anxiously sought for, being considered by some as the only way of obtaining a cure. “Union, (says Mr. O’Halloran) without suppuration, by an immediate coalescence, or by the first intention, is merely chimerical, and is opposite to the rules of nature. Inflammation (contrary to the received canon) is not the time for a reunion of divided parts: This happy minute follows, not precedes suppuration.” It was timidity, with regard to the prevention of suppuration, and want of knowledge of the powers of the animal frame, which so long retarded the progress of surgery, and prevented the improvement of its operations.

The remedies which we employ, with the intention of abating and removing the inflammatory action, are either general or topical.

General remedies are perhaps only useful, or have only a superiority over topical ones, when a general disease, or fever, accompanies the local inflammation. Topical ones are only to be trusted to alone, when the disease is entirely local.

The general remedies, are naturally such as tend to abate action in general, or to diminish the natural action; and, therefore, will consist of bleeding, cold, purging, sweating, nauseating medicines, and some of the agentes dissimiles.

Bleeding is justly considered as the most powerful, and the most useful of all those remedies; and, in many cases, is the only one which can accomplish a cure. The quantity of blood which it is necessary to detract, will be regulated by the effect of the inflammation upon the system, and by the previous condition of the person, with regard to strength; for those who are weak bear bleeding worst; and in them we cannot repeat it so frequently, as in the robust. Delay in them is, however, more dangerous; because the inflammation makes a more rapid progress, and, therefore, we ought sooner to push our remedies.

When the system is affected, in consequence of inflammation of vital parts, the general action is greater than when other parts are affected, and, therefore, bleeding must be used earlier, and with more freedom. Mr. Hunter observes, that when these parts are inflamed, the patient bears bleeding worse than when parts are affected which are not vital; but this observation must not be admitted indefinitely. When these parts are affected, the action is so violent, that the power cannot long support it; and, therefore, we must have early recourse to the lancet, and allow the blood to flow until the pain diminishes, and ceases to abate any more, and until the pulse becomes softer, and perhaps fuller. This is the time to stop; but, whenever the pain returns, or the pulse becomes hard, the orifice should be again opened, although we had bled only half an hour before. The system, in this way, is not weakened, nor the action sunk so low as to injure the power of recovery, which might be the case, were we to bleed too copiously at once. This remark applies, in a particular degree, to inflammation of the bowels; but it may also be extended to pulmonic inflammation; only, in this case, we can detract more blood at a time than in the other instance; because the system sympathises less strongly with the lungs, and, therefore, general evacuation will be longer of operating on the local disease. The same cause, however, makes the danger less; because the general action is not raised so high, and the part itself not being so delicate, can support the action longer, and, consequently, the danger is less. It is an established point, that no action can subside, or be destroyed suddenly, and the patient become free from disease. All morbid actions must subside, more or less slowly, and, therefore, bleeding ought not at once to be pushed so far as to produce fainting, unless the patient be very liable to faint. This sudden cessation of general action does not destroy the specific nature of the action which is going on when it is induced, but rather leaves the parts stationary, the tendency to morbid action still continuing, although the capability to act be suspended for a moment3. In place, then, of bleeding so as to exhaust the strength quickly, and endeavour, as it were, by the quantity of the discharge, to destroy the disease by one bleeding, it will be much better to bleed just until we produce the feeling of weakness to a moderate extent, and abate, to a certain degree, the pain and hardness of the pulse; stopping, whenever we find that we are not abating it farther, distinguishing, however, betwixt real abatement and syncope, or want of power to act and feel. We then repeat the evacuation, whenever the hardness of the pulse and pain return; and thus, perhaps in one day, and with infinitely more benefit, bleed much more frequently, and, perhaps, to a greater extent than is sometimes done in a week, by those who bleed more copiously at once, and repeat it seldomer.

Concerning the exact quantity of blood, which ought, in the different varieties of inflammation, to be detracted, I hold it, from the above principle, to be ridiculous to give any direction; because no general rule can be given, by which we may, a priori, determine the quantity. We are to bleed until we procure an abatement of the action; and to stop whenever this abatement ceases to be really progressive4. We are to renew the bleeding, whenever the action again increases, and stop, as before, whenever it is abated, remembering, that, after some time, a more sparing detraction will produce a greater effect, than a more copious one would do, in the commencement of the disease. It must also be attended to, that, owing to the weakness induced by the disease, and by the bleedings, we must, toward the end, bleed at longer intervals; for, if we continue to bleed in the same way as formerly, we would either kill the patient, or at least prevent the act of restoration from taking place; because we would thus diminish the power, or vital energy, which was to perform this act. Those, then, who order a certain number of ounces to be taken away, must reason upon probability, and prescribe less efficaciously, than those who direct no determinate quantity, but regulate their practice by the effects. It is equally foolish in those who order bleeding, pro viribus, and are satisfied with this until their next stated visit; because bleeding until fainting takes place, and not repeating it for some time afterwards, may be doing a great deal too little.

As there is a proper time for stopping each individual evacuation, so also is there a period at which we ought to stop the general plan of cure by bleeding, or at least to intermit it. And to determine when this period is come, is sometimes a pretty nice point, and one of much importance; because, if we stop too soon, we allow the action still to go on, and, perhaps, to terminate fatally. On the other hand, if we bleed too long, we sink the parts below the state necessary for recovery, and even accelerate the unfavourable termination. When, for instance, from the state of the pulse, and other circumstances, we apprehend the accession of gangrene, bleeding will not abate pain, but will bring on the mortification sooner, and make it spread farther, as will be afterwards mentioned.

As the accession of inflammation depends upon a change of the natural action of the vital principle, so does its removal depend upon the reconversion of this into the natural action, which implies activity, or an active state. If, then, we bleed in the end of inflammation, we lessen the powers of the part so much, as to prevent restoration; gangrene, therefore, will take place: Or, if the part be less delicate, and the progress of the action consequently slower, the inflammation may continue stationary for a considerable time, and become chronic, or habitual. This state is not to be cured by bleeding, but will rather be made worse by it. Whenever, then, after inflammation has continued for a length of time, we find, that venesection does not produce the usual abatement; or, whenever, although there be a temporary abatement, the pain increases afterwards to a greater degree, we may be certain our treatment is improper. We likewise find, that the longer bleeding has been delayed, in the beginning of the disease, the sooner must we stop, and the less quantity must we take at a time; because, in this case, the inflammatory action is nearer its termination, and is more ready to produce gangrene, if the parts be delicate, or the action great, or, if otherwise, the inflammatio assuefacta. We are also to refrain from bleeding, when we find that the inflammatory action is about to terminate in another action; as, for instance, the suppurative; because, in the first place, bleeding, in this new action, can do no good, but, by weakening, will do harm; and, secondly, if there be only a tendency to this action, the action not being yet formed, or beginning to form, we may, by bleeding, interrupt the progress of the inflammation, and convert it into a more tedious disease, or the inflammatio assuefacta.

Bleeding has been used, not only as a cure for inflammation, but also as a preventative; but this must be considered as proper, only in particular instances. When, for instance, an wound has been inflicted, or an operation necessarily performed, on a robust person, bleeding immediately, or very soon after it, may be useful; because it will tend to lessen the chance of the natural action being carried so high as to become changed. These people cannot have their action much increased without disease; and, therefore, it is necessary to lessen it, and bring it down to a more proper medium. But there are other cases, where the action is naturally rather too low, and the patient weakly. In these cases, bleeding can do no good, but much harm; because it increases the previous weakness, and makes the inflammation, if it does occur, more dangerous, on account of the little power which there is to support the action. These people even bear bleeding worse than others, when inflammation has actually taken place. It ought never to be practised, in order to reduce the natural action, before disease has taken place; and, after the inflammatory action is induced, it ought to be used cautiously, and only to such an extent, as may be necessary for removing the tendency to immediate bad consequences. It ought, however, to be used very early in the disease; because, in weak people, the action does more harm in a given time, than in the strong; but it ought likewise to be sooner abandoned, otherwise we either hasten mortification, or prevent the act of restoration from taking place.

Bleeding is rarely necessary in inflammation of the cellular substance alone, unless the action be extensive; in which case, the system is so affected, as to require our interference. When the cutis is inflamed, producing erysipelas, the system suffers considerably; but, as this frequently ends in mortification, bleeding has been neglected by many; but it is evident, that, if the disease be simple, and not dependent upon any specific agens dissimilis, or epidemic contagion, venesection is the proper cure, provided it be early employed, as we thus diminish the action more certainly than by any other means. If, however, the disease have been neglected, and the action be nearer a termination, then we must either do nothing in the way of general treatment, or must give opposite remedies from bleeding, according to circumstances. When muscles are inflamed, bleeding is often necessary to a very great extent, as we observe in rheumatism; and, in the beginning, we must take a greater quantity at a time, in order to procure an abatement, than in many other cases. When the viscera are inflamed, bleeding is uniformly necessary, and generally requires to be frequently repeated.

It is a common opinion, that the blood ought to be taken, if possible, from a vein which arises from, or near the affected part; that, for instance, in phrenites, we should bleed in the jugular vein; in inflammation of the feet, we should bleed in the leg, &c.: And, when this can conveniently be done, it may be preferred; because, it not only possesses all the advantages of general bleeding from any other vein, but also may be supposed to produce, in a slight degree, a topical evacuation. If, however, the veins be so small, that we cannot detract enough of blood, and sufficiently quickly; or if, from any other cause, we cannot do so, then, if the general action be violent, we must have recourse to another vein, as the loss to be sustained, by confining ourselves to this vein, is infinitely greater, than any good which can be derived from it, as a local evacuation. Indeed, when we consider the laws of the circulation, we must allow, that very little good can be done in this way, as a local detraction; because one vein does not lose more blood than another, except during the moment of the flow.

The blood, when drawn during inflammation, has always a buffy coat, which is, in general, thicker, and more concave, in proportion to the violence of the inflammatory action; and the continuance of this condition, is one circumstance which points out the necessity of continuing our evacuation: But the mere existence of a buffy crust, is not, without these circumstances, any infallible sign of the necessity of bleeding; because this crust is to be found on the blood, after the inflammation has begun to become passive; and it is to be found also, when mortification is approaching; we observe it likewise very frequently upon the last cup of blood which we find it necessary to take away. In these cases, however, the crust is much softer, generally thinner, always flat, instead of concave, and looser in the texture; it is also more of a greenish hue. These circumstances, conjoined with the state of the pulse, will enable us to judge, whether we should totally desist from, or continue our evacuations with caution. Most frequently they forbid farther bleeding.

Cold, or the subduction of heat, is chiefly useful as a topical application; but it is also proper to be applied, in moderation, for the abatement of the general fever, unless we be desirous of procuring perspiration. The quantity of bed-clothes ought to be lessened, cold drink should be allowed, and a free circulation of cool air into the room. The application of cold, however, ought, in general, only to be carried to such an extent as shall be sufficient for diminishing the morbid degree of heat, and not so far as to produce sensible cold, or the sensation of cold; because this, in many instances, will be pernicious, upon the principle of the sympathy of equilibrium, the action of the internal parts being increased by the speedy application of cold to the surface; and, therefore, if the internal parts be inflamed, their morbid action must be still farther increased. If the cold be long applied, to any considerable degree, it will likewise, by the sympathy of association, weaken the whole system too much, and injure the act of restoration. As bleeding is to be used only until it restores a natural state, and abates pain, so also is cold only to be applied in such a degree as may be necessary for diminishing the preternatural heat, and sensation of the surface; which it does, by lessening the morbidly increased action, and reducing it to the natural state. The degree must therefore gradually be diminished, in proportion as the general disease subsides, otherwise we injure the system, and prevent recovery. There is, however, this difference betwixt bleeding and the application of cold, that the first may be used suddenly, and to a considerable extent at once, whereas, the second ought, especially in all cases of internal inflammation, to be employed more slowly, and its degree regulated by the degree of the general heat of the surface.

Nauseating medicines are also very useful, independently of the sweating which they frequently induce; and are a very powerful mean of abating action in general5. Employed, after bleeding has been used once or twice, they are productive of considerable benefit; but there are some affections, in which they cannot be used, such as inflammation of the stomach and intestines; but in inflammation of the lungs, of the throat, muscles, or surface, they may often be prescribed with benefit. The remedies usually employed for this purpose, are, small doses of emetics, given without drink. It must, however, be remembered, that these frequently produce considerable evacuations, either from the skin or bowels, and, therefore, may occasion a permanent weakness. We must likewise avoid raising the sickness to a great degree, and keeping it long up; because the same objection applies nearly to this as to bleeding ad deliquium.

Purging is frequently employed in the cure of inflammation, especially such purgatives as are called cooling, which, in this case, is an imaginary quality; but, unless in so far as they tend to abate the irritation of costiveness, they can do no more than bleeding can, and are, in many respects, inferior to it. They are, in one view, to be compared with the application of cold, which is only indicated when there is much heat; both are intended to diminish action, chiefly by removing stimuli from the part to which they are applied. Purging is very uncertain in the effects which it produces on the system, and in the degree of weakness which it causes; and, therefore, never can be put in competition with bleeding, as a general remedy; and, wherever bleeding is improper, or its propriety doubtful, purgatives are still more injurious. They operate likewise so slowly, at least comparatively speaking, that they do not influence the local action so much, as the loss of such a quantity of blood, as would produce an equal effect on the body, will do, unless in particular cases, when they act upon the principle of the sympathy of equilibrium; as, for instance, in pulmonic inflammation, when they sometimes are of service, by increasing the action of the intestines, and diminishing that of the lungs6. In the same way, emetics sometimes cure slight inflammation of the tonsils. One of the best and pleasantest saline purgatives, is the phosphate of soda, which may be given to an adult in the dose of an ounce, in order to obviate the effects of costiveness. If we wish to use it, upon the principle of the sympathy of equilibrium, we must give two ounces, or more. The same cautions which were given, with regard to bleeding, apply also to purging.

Sweating, considered as a mean of abating general action, is, in most cases, inferior to bleeding; and can never, when the general inflammatory action is considerable, be trusted to alone; but, after the use of the lancet, it is generally serviceable. It is useful, in particular, when the local disease is not confined to a small spot, but affects a considerable surface, or different parts of the body; as, for instance, in the rheumatism; but it acts, in these cases, rather by the sympathy of equilibrium, than by any other mode. At the same time, the induction of a sweat, preceded by bleeding, (which tends to abate the local action as well as the general one) will sometimes be useful, by giving a secretory termination to the general disease, and hastening its conclusion. In the first point of view, sweating may be used early in the disease, especially if preceded by bleeding. In the second, it will be chiefly useful toward the end, as it will then accelerate the termination, and thus influence the local action; for the abatement of the general action must also produce an abatement of the action of a particular part. Sweating, as well as purging, must be used with caution in weakly people, or in those who are reduced by disease; because, although the action of particular parts may be increased by it, yet, partly in consequence of this temporary increase, and partly on account of the fluid which is discharged, general weakness is induced. One of the best sudorifics is the pulvis ipecacuanhÆ comp.; of which we may give ten grains every hour, until sweating be produced, giving warm lemonade alongst with it. The tartar emetic is also a very useful sudorific; the sixth part of a grain may be given every half hour, until the proper effect be produced7.

Some of the agentes dissimiles may be considered as proper remedies in this complaint; such as, digitalis, laurel water, lead, &c.; But they are certainly inferior to blood-letting; and have been so little employed in this way, that their effects are not ascertained8.

Bleeding, of all the general remedies, is the best; and, next to that, cold, and nausea, which may be considered as useful adjuvants. Sweating and purging are mostly to be used when particular indications present themselves, as may be understood from what has been already said. The first of these remedies, act chiefly by producing an universal abatement of action; and, of these, bleeding produces the most permanent effect on the body, and the most certain effect on the local disease. The two last are perhaps more useful, upon the principle of the sympathy of equilibrium, than that of abating action in general, which is only a secondary operation; and, therefore, they may be considered as remedies, acting rather topically than generally; for, according to this view, they act chiefly on the affected part. These two kinds of remedies may, in many cases, be usefully conjoined, producing thus a greater effect than either would do singly.

Before quitting this subject, it may not be improper to attend to the proposal which has been made, of exhibiting anodynes immediately after bleeding, in order to remove the pain. “The most effectual remedy for this purpose, (says Mr. Bell) is opium, which, when pain and irritation are considerable, as in extensive inflammations very frequently happens, should never be omitted. In large wounds, especially after amputations, and other capital operations, in punctures of all kinds too, large doses of opium are always attended with remarkably good effects. In all such cases, however, opium, in order to have a proper influence, should, as we have observed, be administered in full doses, otherwise, instead of proving serviceable, it seems rather to have the contrary effect; a circumstance which is perhaps the chief reason why opiates in general have been very unjustly condemned, in every case of inflammation.” That, in every case of inflammation, opiates are hurtful, is what no one can assert; and their utility will afterwards be fully manifested. But, that opium is useful, or even harmless, in the inflammatio valida, which we are at present considering, cannot be admitted; because daily experience, independent of every theory, proves, that, by their use, the general fever is increased, and the local action aggravated. Even given as a preventative of inflammation, after operations, anodynes are almost uniformly hurtful9, producing restlessness, heat, and thirst, and afterwards head-ache, sickness, and frequently troublesome vomiting. I have therefore now, after almost every operation, laid aside their use, and find, that the diseased action10, subsequent to the local irritation, runs its progress with much less disturbance, and is much milder, and shorter, than where anodynes have been administered; and, in general, the sleep is much more composed, and always more refreshing. I have therefore, after lithotomy, amputation, the extirpation of the mammÆ, and after labours, in almost every instance, omitted them.

The local applications are such as tend either simply to abate action in the part, or such as tend to change its nature, by exciting a specific change, or such as act in both ways. The first comprehends cold, the second the agentes dissimiles, and the third topical bleeding.

Cold, applied directly to the inflamed part, is a most useful remedy, diminishing the action to a natural state; but, for this purpose, it must not be applied in too great a degree, otherwise we diminish the action so much, and so suddenly, (and, consequently, the power of the part) that recovery cannot take place. If we apply much cold to a healthy part, we sink its action so far, that it is irrecoverable; if we apply cold to an inflamed part, so as to diminish its action equally suddenly, and in the same proportion, we produce the same effect. Poultices of ice, or snow, are therefore highly dangerous; and even water, although it cannot be made nearly so cold as these. The same direction which has been given, with regard to the application of cold as a general remedy, ought also to be remembered, when we use it as a local application, namely, it ought to be carried just to such a degree, as shall diminish the morbid sensation, and ought to be so adjusted, as to keep the part nearly in its natural degree, or at least very little lower. For this purpose, it must be applied in moderation, repeatedly, and with assiduity; and not, as is commonly done, in a considerable degree at once, and renewed only at long intervals. Cold has been supposed to be useful as an active astringent, producing a contraction in the vessels; but it does not seem to possess any active power in producing such a state in the vessels to which it is applied. Where injury is taking place, from excessive action, cold, by abating it, may strengthen, and produce more natural contractions; but, when applied to a healthy part, it diminishes the action of that part, the blood is less forcibly circulated, and the part shrinks; it therefore stops active hemorrhage in the part on which it acts. When cold is applied suddenly, or to delicate parts, it excites an universal action, or contraction, or shrinking, from weakness; and, therefore, may likewise stop hemorrhage from distant parts. In many cases, when this shrinking, or temporary contraction, is suddenly induced by cold, it becomes converted into the natural muscular contraction of the part; thus, for instance, if cold be applied to the uterus itself11, when torpid, after delivery, we find, that, after the first effect, or shrinking of the vessels, a more natural contraction takes place. If, however, cold be long applied, we find, that the contraction thus induced ceases, owing to the diminution of action which is occasioned by its continuance, and the original state of collapse, or shrinking, alone remains.

Blisters likewise act by simply abating the action of the part; but differ from cold, in requiring to be applied, not to the part which is affected, but to some other, with which it exhibits the sympathy of equilibrium; as, for instance, to the integuments of the thorax, in pulmonic inflammation; to the skin of the knee, in affections of the joint, &c. It is, however, necessary, when a general disease, or fever, is induced, that bleeding be fully employed, before we have recourse to blistering; because, if it be not, the inflammation, excited by the blister, co-operates to increase the fever, alongst with the original disease, which it has not had time to overcome, or lessen. Blistering likewise acts more effectually, when the local action has been already diminished, by previous bleeding. The size of the blister should be proportioned to the probable extent of the diseased action; at the same time, we must set bounds to this magnitude; because, if too large, they may not only produce, or keep up a general disease, but also, by lessening the action of the internal parts too much, and too quickly, they may prevent recovery12. It is therefore better to apply them of a moderate size, and renew them frequently, than to apply one too large at once. It must, however, be remembered, that inflammations of every part are not equally readily overcome in this way; and, therefore, one will require a larger blister than another; thus, the same quantity of inflammatory action in the brain, will be more difficultly subdued, than in the breast; and, therefore, we must apply, in that case, a larger blister. As it is the inflammatory action, induced by the blister, and not the discharge, as was once supposed, which is useful, it follows, that the same blistered place should not be kept too long from healing, or in the state of an issue, but that we ought rather to apply a succession of blisters; and this succession should be pretty rapid. There is indeed one case, in which issues are admissible, namely, where, from the nature of the inflamed part, or the peculiarity of the inflammation, if it be specific, or scrophulous, the progress of the action is very slow. In these cases, a rapid, and continued succession of blister would, doubtless, be most useful, but, from the duration of the treatment, would scarcely be submitted to: Issues, which are less painful, and less troublesome, are, therefore, generally preferred. We have an instance of this in many diseased joints.

The remedies which tend to diminish the inflammatory action, by producing a peculiar, or specific change, are, the agentes dissimiles, of which, for this purpose, lead is the best, and the one which is most frequently employed. Lead, in the state of an oxyde, was long ago used; but it does not appear, in this condition, to have much activity; and, therefore, the saline preparations are now introduced into use. The acetite of lead, on account of the supposed power of vegetable acids in abating inflammation, has been considered as possessing a great superiority over other forms; but its chief recommendation over other soluble preparations, is its cheapness; for the nitrate of lead seems to be equally powerful. The acetite of lead may be employed, either before or after crystallisation; but, if we use the crystals, they must be redissolved; for which purpose, soft, or distilled water, must be employed, otherwise a decomposition takes place. The strength of the solution which we apply, must be determined by the natural delicacy of the part, and its morbid sensibility, in consequence of inflammation. In the inflammatio valida, in which alone it is proper, the solution never ought to be so strong as to produce pain. When the eye, urethra, and other delicate parts, are inflamed, the application ought to be just so strong as to produce sensation, and should be very frequently repeated. When the cellular substance is inflamed, and we begin the application before the cutis be much affected, the solution will not require to be so strong as to produce sensation; because, were it to be so, the action excited might, from the quantity required to produce the effect, be so great, and so suddenly induced, that the powers of recovery would be lost, or a specific inflammation be occasioned, as we observe, when the solution is very much concentrated, in which case, even sloughs are sometimes produced. On the same account, we must renew the application frequently, at least if we use pledgets, otherwise the evaporation of the solvent increases the strength more than we desire. For incipient phlegmon, we may employ a solution consisting of three pounds of rain or river water, and five drachms of sugar of lead; or the following, which is more elegant:

R. Cerussa AcetatÆ dr. iii ss.
Aceti Vini unc. iii. Solve super focum dein adde.
Aq. Distill. Frigid, lb. i ss.
Aq. Rosar. unc. iv.

This may be applied by means of pledgets of linen; or part of it may be made into a poultice, with crum of stale bread.

Saturnine poultices ought always to be applied cold; because we thus receive both the benefit of the cold, and of the lead. The directions which have already been given, with regard to the application of cold, are to be attended to here.

Lead has been supposed to act as an astringent; but, if astringents were useful, alum would be more effectual than any of the preparations of lead.

The vegetable acids have been considered as sedatives, and are generally employed in the cure of inflammation; but it would rather seem, as if they belonged to the class of agentes similes; for, in moderate quantities, they increase the appetite, &c. which no sedative, or agens dissimilis, ever does13: They also excite a general action, which is different from that induced by sedatives, and which is useful in curing many of the actions induced by these agents. We likewise find, that they are not serviceable, as local applications, in the cure of inflammation, unless in so far as they become the vehicle for applying cold. The surface is not very susceptible of their action; and, therefore, those who are inclined to continue their use, may do so without injury, and even with benefit, if they be cold; but then the same benefit will be derived from cold water.

Alcohol is likewise considered by some as a sedative, and introduced as a remedy, in the enumeration of those which are applicable in inflammation14; but, whatever its use may be in the inflammatio debilis, it must be allowed to be evidently hurtful in the inflammatio valida.

The last division of local application, contains those which tend, both simply to abate action in general, and also to excite, to a certain degree, a specific change of the action. Topical bleeding is the chief remedy belonging to this division. Bleeding with leeches, or the scarificator, is employed in two different circumstances: First, when we detract directly from the inflamed part; as, for instance, from the surface of a phlegmon: Secondly, when we detract only from the neighbourhood of the inflamed part; for instance, from the skin which covers an inflamed joint. When we employ topical bleeding, in the first case, we may suppose, that the aperture, and effusion from the extremities of the inflamed vessels, produces, to a certain degree, a change of action. Every action of the vessels is performed at their extremities, and the trunks and branches may be considered as canals subservient to the extremities, and which contract and dilate, in a degree proportioned to the general and local action. If, during health, we open a number of the extremities of these vessels, we induce the hemorrhagic action, which continues longer or shorter, according to circumstances, and which gradually terminates in a serous discharge, or secretion. If, during inflammation, we open a number of the extremities of vessels, either in the inflamed part, or immediately contiguous to it, we induce a similar hemorrhagic action, which is different from the inflammatory one, and, therefore, tends to diminish that action in the part. We likewise, by inducing the serous secretion, tend to produce a termination to the inflammatory action.

Topical bleeding will also, in part, operate, by simply abating the action, in consequence of the mere loss of blood; for, as the blood is withdrawn immediately, by different orifices, from the vessels of one part, that part, and those near it, may be supposed to suffer sooner, and to a greater degree, than the rest of the system. The branches which yield the blood, will even suffer considerably, for a time, although the loss of blood be very trifling, and produce no effect on the system. Thus, if one small artery be divided, we find, that, although the quantity of blood which flows from it be very inconsiderable, yet it is sufficient to produce evident changes in that vessel, making it contract, and become smaller, although the vessels in other parts be not at all affected. This depends upon the peculiar15 action of the individual artery being affected16, and the contracting state of the orifice, spreading along the branch and trunk by degrees17, by which less blood is made to circulate through it. Bleeding from a vein, however, has not the same effect; because the quantity of blood in a part, is not so immediately dependent upon the state of the veins; and because veins are not the seat of much action. When we divide a small vein, we find, that it, by degrees, contracts, and transmits less blood, or closes completely; but the blood from the part does not circulate faster, nor is less blood sent to that part than formerly; therefore, topical bleeding from veins near the affected part, can have no great superiority over general bleeding.

The division, then, of a number of small arteries, may cure inflammation in two ways; first, by inducing a different action; secondly, by possessing the general properties of bleeding, namely, a simple diminution of action. The first will operate chiefly, when we apply the leeches on part of the inflamed portion. The second will operate, when we detract only from the immediate vicinity; and, in this case, the quantity of blood which is taken away, must be greater; because the effect has to be extended some way, the vessels not being in the inflamed part. The quantity must likewise be greater, because the effect depends entirely upon this; whereas, in the other case, it depended, in part, upon the peculiarity of the action which was produced.

The number of leeches which it is necessary to apply, will depend upon the violence of the action, and the place on which they are set; for, the greater the distance from the inflamed part, the more numerous ought they to be. It is therefore impossible to give any particular rule for the extent of topical bleeding. It may, however, be proper to observe, that we ought not to be satisfied with one application, more than with one venesection, for a general disease, but ought to repeat the local bleeding, whenever it may be necessary, although it may be twice or thrice in a day, founding our indications upon the same principle on which we use general bleeding. It is by a too sparing application of leeches, and their not being repeated sufficiently frequently, that we so often fail in removing inflammations, which, by a more active treatment, we might resolve. In general, the leeches ought to be applied as near the affected part as possible, or upon it. If, however, the seat of the inflammation be chiefly in the cutis, as in erysipelas, it will perhaps be more prudent not to apply them upon the spot; because the subsequent irritation is apt to increase the action afterwards, on account of the great delicacy of the part. There may even be some doubt as to the propriety of applying leeches to the vicinity of the inflammation; for the irritation of the bites may produce erysipelas in the part, or cause the original disease to spread.

The scarificator may be used where leeches cannot be obtained; but it is not so useful, when applied to the inflamed part, on account of the irritation which attends its application, and the cupping; but it is equally proper, where we detract not from the part itself, but from its vicinity.

Of the topical remedies, bleeding is the most powerful; and, next to that, cold solutions of lead. Where these cannot be employed, owing to the internal situation of the inflamed part, blisters must be used in their place.

Many other remedies used to be recommended, under the name of discutients, repellants, &c.; some of which have been formerly mentioned, when considering the ancient theories of inflammation; these, however, are now laid aside. But many practitioners still have an idea, that benefit will be derived from mechanically softening the parts by means of oils, or what they call emollients; and seem to consider, that poultices are chiefly useful for the same purpose; at least they only direct, that they shall be removed before they turn “stiff or hard.” But inflammation must be attributed to a different cause than increased attrition, and its cure must be effected by different agents from those which we employ for softening a piece of dead skin. Oils and liniments, in so far as they form a basis for other applications, or are used alongst with gentle friction, may be occasionally proper in the inflammatio assuefacta; but, in the inflammatio valida, they must be considered as absolutely useless.

There are also some remedies, recommended with the intention of absorbing acrimonious excretions; such as, flour or magnesia, in erysipelas. But these seem to act entirely by allowing the action to run its course, without interruption, affording a softer defence than could otherwise be obtained. From the quick progress of violent cuticular inflammation, the applications which are usually made in other inflammations have been forbid here, and are said to be pernicious; but this rather appears to arise from the application not being properly timed, than from any peculiarity in the disease. It is not easy to give any good reason why cold saturnine solution, of a proper weakness18, and sufficiently early applied, should not be useful; nor do we find, that they are in reality hurtful in simple erythema. Where this, however, attends wounds, or is not an original disease, these are improper; because it is in general, in these cases, an attendant upon the inflammatio debilis, or a symptom of it, and requires either to be let alone, or to have stimulating applications made to it, at the same time that we give bark internally19.

These remarks upon the resolution of the inflammatio valida, may be concluded, by observing, that the diet ought to be low and sparing, in a degree proportioned to the violence of the action. Such motion as affects the local action, must at all times be prevented; but when a general action likewise exists, then general quietude must also be insisted on.

Of the Remedies which are necessary for inducing Suppuration.

Suppuration is a new action, the exciting cause of which is inflammation; but, that it may take place, it is requisite, that the inflammatory action be prevented from subsiding too soon, or too suddenly; in which case, either resolution, or inflammatio assuefacta, takes place: Whilst, on the other hand, we must prevent the action from rising too high, and proceeding too rapidly; in which case, mortification is caused.

In these cases, in which resolution cannot be obtained, suppuration will generally take place, without any interference on our part, provided we prevent the action from terminating in gangrene. This we observe in many internal inflammations. At the same time, we may sometimes accelerate this process, by a proper regulation of the original action.

The remedies proper for moderating and removing the inflammatory action, have been already mentioned; but these sometimes fail to produce resolution; in which case, either suppuration, or mortification, take place. When the symptoms of suppuration take place (which have been already noticed), all that is perhaps essentially necessary, is, to give up the resolving plan, and not interrupt the natural progress of the action. If, however, the inflammatory action continue longer stationary, and seem neither to be resolving, nor decidedly inducing the suppurative action, then such remedies as increase the action, and accelerate its progress, are essentially requisite. These remedies, however, are, in general, indiscriminately applied in both cases.

For the purpose of inducing, or accelerating the suppurative action, it was formerly the practice to apply liniments, cataplasms, and fomentations, composed of stimulating substances, such as garlic, turpentine, galbanum, &c.; but of late these have been almost entirely abandoned. Heat and electricity have the property of increasing the performance of every action which is existing at the time of their application, and, therefore, are the remedies chiefly to be employed in the present instance.

Heat may be applied in two ways, with or without moisture. In the first, it increases action more suddenly, and perhaps more simply. In the second, its effects are more gradual, and are likewise complicated with those of moisture, which certainly is an agent capable of operating on the living system, and generally tends to excite a secretory action, or to give a secretory termination to those increased actions, which are induced by agents operating alongst with it. Dry heat is therefore evidently improper in the inflammatio valida, because it will tend to produce mortification; but, if moisture be conjoined, then the suppurative action is excited. When, however, the action has made an approach to the inflammatio assuefacta, then it may be useful to raise the action simply by dry heat, for a little, before we apply heat and moisture; because, if we apply moisture at first, the progress is more tedious, and the action is less certainly excited20. Electricity is similar in its operation to heat and dryness, and may be usefully employed in similar cases; but we must, if we expect any benefit, repeat its operation frequently, and continue each application for a considerable time21.

There are two forms in which we employ heat and moisture, namely, fomentations and poultices. Fomentations22 have this superiority over poultices, that the same degree of heat is always kept up during their application; whereas, when we use poultices, the heat subsides, as they are renewed only at considerable intervals; but fomentations require longer attendance, and more trouble; and, therefore, are only employed for a short time, and commonly betwixt the intervals at renewing the poultices.

Poultices are generally made of bread and milk boiled together, so as to form a thick kind of paste, to which is added, so much olive oil as will preserve it from hardening quickly23. These ought to be applied, either of the same temperature with the inflamed part, or hotter, according to circumstances. When the inflammation seems to be naturally and quickly tending toward suppuration, it is, as has been already mentioned, by no means essential, that any application be made externally, in order to induce the suppurative action24; but still poultices are used, and, in many cases, accelerate the progress. In this case, the poultices should only be applied so hot as not to give any considerable sensation of heat, otherwise we increase the action too much, and too rapidly, and, if early employed, may even interrupt, or stop the incipient purulent action, renewing the inflammation, and perhaps making it terminate in partial gangrene. Poultices, then, should not be applied very hot at first, especially when the action seems to be such as to make us expect that it shall run its course without any assistance. But when the inflammatory action has been more tedious, and does not terminate in the suppurative one so soon, and so decidedly as we would wish, then poultices must be applied, with a different intention, being meant, not solely to prevent the action from sinking, as in the first case, but also to raise it, and make it brisker. The heat must therefore be greater, and such as to give a considerable sensation; and the poultices, instead of being changed only when they begin to grow hard25, which is perhaps all that is necessary in the first case, must be renewed very frequently, in order to keep up the increased degree of heat, or the agent which supports the action, and accelerates its progress. They ought, in this case, to be taken off and warmed, or renewed almost every hour, at least when the action is tedious, that is to say, when they are most required. We are then not to lay down any certain degree of heat which is to be employed, nor fix any particular number of times at which the poultices must, in every instance, be changed, but regulate our practice entirely by the nature of each particular instance, taking the progress and degree of the action as our guide, in this respect, and interfering exactly in proportion to the necessity for interference. It may not, however, be improper to remark, that, cÆteris paribus, the heat must be greater in proportion to the depth of the inflamed part below the skin; or, in other words, we must apply more heat, when we are obliged to act on a part not yet inflamed, than when we act directly on the inflamed part itself. When an abscess forms at a distance from the surface, the parts betwixt it and the surface gradually come, as was formerly mentioned, to assume the purulent action; and the sympathy of equilibrium, which naturally exists betwixt the surface and the parts below, gives way to the sympathy of association26, the parts coming, by degrees, to perform one uniform action together, which spreads from within to without. When we apply heat to the surface, at this place, we, by continuance, likewise induce the sympathy of association, and the increased action spreads and operates on the disease; but there is this difference, that the action of the heat spreads from without to within, and thus accelerates the progress of the suppurative action.

When the suppurative action has existed a certain time, we find, that it gradually extends itself to the skin, purulent matter being formed, instead of organic particles; on which account, the cavity enlarges, and the covering becomes daily thinner. At last, the action reaches even to the cutis, which becomes white and flaccid, first at a point, and then to a greater extent27. When this happens, the thin covering is either torn by the pressure of the contained fluid, acted on by the surrounding parts, or acting by its own weight; or, if this does not take place, the suppurative action still proceeds going through the cutis, the organisation of which, like that of the parts below, is lost: The thin cuticle now rises up into a little blister, and then gives way. The matter runs gradually out, the sides collapse, and come nearer by degrees to each other, at the same time that the ulcerative action succeeds to the suppurative. The quantity of the discharge, therefore, daily lessens; the internal surface, or sides of the abscess, come in contact; and the granulations at the margin or circumference unite; those belonging to one side uniting with those of the other, and thus producing recovery by successive circles of reunion, which form rapidly, or more slowly, according to circumstances.

Such is the natural progress of an abscess; but it has been proposed, that it ought not to be allowed to follow this, but ought to be opened before it bursts spontaneously; and this opening has generally been desired to be pretty large, chiefly perhaps on the principle of allowing a free evacuation of the matter. Where abscesses are seated over cavities into which they may burst28, instead of opening externally, there can be no doubt of the necessity of making an early evacuation; and, in these cases, we ought to open them before the skin becomes white; or, in other words, before the action reaches the surface; because, if the abscess be seated equally betwixt the skin and the cavity below, we may suppose, that, if it be extending itself in all directions, or toward the cavity29, in the same proportion as outwardly, that the parts below will become almost irreparably diseased before it can reach the surface, and will give way afterwards30, even although an opening be made externally. Where, from the confinement of the matter, it seems to be spreading, or diffusing itself, by its gravity, through the cellular substance, or among the muscles, it will likewise be necessary to open the abscess early; but, in this case, the abscess is unhealthy; for, were it otherwise, the matter would be confined by the circle of diseased organic matter thrown out during the inflammatory action, and which is only removed gradually. In this case, the suppurative action has extended itself laterally, and perhaps downward, more quickly than in health, and has not observed the same ratio, with regard to the extension toward the surface; the action, therefore, reaches parts which were not formerly inflamed (by the sympathia consociationis serpens), before the surface gives way; and, therefore, the matter spreads or diffuses itself; for, by the spreading of the action, the confining barrier is removed, and the matter mechanically extends itself. This is an unhealthy abscess, and the action is of the phagedenic nature. Opening the abscess will not always stop this morbid action; but, by removing the matter, it will lessen the chance of diffusion. We must, however, continue the free evacuation, and place the member in a proper posture; because, if the action continue, the matter which still is formed will lodge, and form sinuses.

In healthy abscesses, where we do not apprehend any detriment to the neighbouring parts, the question comes to be, whether opening them will accelerate the cure? Perhaps much of the diversity of opinion on this subject, has arisen from not attending to the condition of the abscess which we have been managing, and thus we apply the prognosis and treatment of one kind of abscess to different ones. When an abscess has been formed slowly, and runs its course rather tediously, we may suppose, that the action shall continue for a considerable time without being converted into the ulcerative one; and, therefore, the abscess shall remain long without healing. In this case, a free incision, or the irritation of a foreign body, may excite the ulcerative action, and thus accelerate the cure; for these abscesses have come to approach toward the nature of common encysted tumors, and require the same treatment. But, where abscesses are running their progress with due celerity, and the action is proceeding through its proper course, there is not the same cause for interference. If, in this case, we open them before the action has gained the surface, we derive no benefit; because the action still proceeds, and the same events and circumstances take place as if we had allowed it to burst. If we make a large aperture, when the abscess is ready to burst, we, by the irritation, interfere with the process which was going on, and delay the cure. The admission of the air to the abscess, owing to the free exposure, is one cause of this delay; for it changes the nature of the purulent action, and, if the ulcerative action takes place, frequently renders it unhealthy; the consequence of which, if the abscess be large, or situated in vital parts, is hectic. We likewise, in large abscesses, by the sudden evacuation of the matter, and removal of the distension, sink the action of the parts, and make covery more tedious31. When the abscess, then, is healthy, and the action strong, it will be more proper to allow it to follow its natural course, and burst spontaneously, than open it, by a large incision, or by the introduction of a seton: If we do open it, the orifice should not at first be large, but should just comprehend the diseased or whitened surface.

Sometimes, after an abscess has burst, or been opened, it continues in a progressive state of amendment for some time, and then becomes stationary, continuing to discharge matter without healing. This either takes place from the whole surface, or from a particular part of it, forming a sinus, the treatment of which will afterwards be mentioned, being the same with those which succeed abscesses which are originally unhealthy.

After an abscess bursts, the proper application is a warm poultice32, which should be continued in general as long as there is any stool, or hard margin; that is to say, until the increased quantity of diseased organic particles, which were formed during the inflammation, be absorbed, and the vessels at that part have either assumed the suppurative or natural action. After this, the orifice ought to be covered with a slip of lint, and moderate pressure applied over the surface of the abscess33, by which the sides are kept in constant contact, and reunion is accelerated. Good diet is also necessary, for we thus increase the powers of recovery, or keep up a proper action, and renew the vital principle, the quantity of which has been lessened during the inflammation, both by the continuance of a state of overaction, and by the remedies which are employed to diminish the action; for a state of real and permanent weakness is thus induced.

It sometimes happens, that suppuration takes place very slowly, and the action seems to be performed with little vigour. In this case, if the abscess be allowed to burst of itself, we both lose time, and are often, in the end, disappointed in a cure, the healing process not taking place. It is therefore useful, in these cases, to have recourse to other agents besides heat. If the pain be trifling, and the suppuration be what may be called chronic, or approaching to it, we will perhaps succeed, by applying gentle pressure on the abscess, by means of a thin roller, and laying a warm poultice over this. But, when this fails to increase the action, we ought to pass a seton, by which we evacuate the matter, and keep up the subsequent action to a degree sufficient for producing recovery. In doing this, however, it is necessary to attend to the state of the tumor; because, if, in every instance, we pass it from the highest to the lowest part, we shall sometimes make the part give way in a third place. If, for instance, the abscess be much thinner at the apex than elsewhere, or, if the action have made considerable progress toward the surface, then the stimulus of the action increases the performance of the natural process which was going on, and the action continues to extend itself until the part gives way. In these cases, then, we ought to pass the seton from the thin part to the lowest part; and this, in general, will, from the sympathy of association, be sufficient to excite the action of the whole internal surface.

When we resolve to use the seton, the following is the easiest method of introducing it: Make a puncture with a lancet either into the upper, or the thinnest, and most prominent part of the tumor, according to circumstances; and, into this puncture, introduce, using the lancet as a directer, a probe, having a piece of tape passed through its eye. The lancet is then to be withdrawn, and the probe pushed down to the under part of the abscess, where its point will be felt under the skin. A small incision is here to be made upon the knob of the probe, which is next to be passed through, and the tape drawn after it. The matter is then to be slowly pressed out; the tape is to be folded; and the abscess bound up with a compress and roller, so as to make moderate pressure upon it. Next day, the dressings are to be removed, and a clean piece of the tape drawn through, after which, pressure is again to be applied.

The size of the tape, the time which the seton ought to be employed, and the degree of pressure to be used, must be regulated by backwardness of the action, and the imperfection of the healing process.

If, either from improper management, or the morbid condition of the action, the abscess, after it bursts spontaneously, or is opened by art, continue to suppurate, without undergoing the ulcerative action preparatory to healing, then we find, that either the sides remain quite separate, producing a cavity, extended more or less, or one particular portion remains open, forming a sinus. Both of these cases require a treatment, which, in its principle, is the same, namely, the indication of the ulcerative action.

In the first case34, we shall frequently succeed by means of the seton, especially if we use pressure alongst with it; for, by keeping the internal surface in close contact, we tend to check the purulent, or suppurative action, and produce organic particles35. We may also succeed, by using stimulating injections, of such a strength as to produce a moderate degree of smarting. Of this kind are, wine and water, solutions of white vitriol, corrosive sublimate, &c. These ought to be used frequently in the course of the day, and pressure employed during the intervals. Incision, or laying the part open, is, being the most severe, the last remedy which is to be had recourse to. Small chronic abscesses may be laid open during their whole diameter; but larger ones require only to be cut up for a certain length.

The second case, has generally been considered as a species of ulcer, and has been named the sinus ulcer; but, although the orifice may sometimes possess the diseased ulcerative action, yet the sinus itself still continues in the suppurative state, and, therefore, cannot heal. These sinuses depend, in different instances, upon very different causes, and, therefore, require a variation in the treatment. The most simple species of sinus may be called mechanical, and is produced by matter flowing from a neighbouring cavity, and which cannot be freely discharged: Thus, for instance, if a deep abscess open at the highest part, or at a point above the level of its bottom, the matter constantly oozes out, and keeps the canal open. This is most apt to occur, when abscesses are formed deep amongst muscular parts; in which case, although the matter point at the centre, yet an accumulation must take place below, and the matter must continue to be discharged by the aperture, when it becomes so abundant as to be raised to the level of the opening; or, being once raised, it continues to flow out. The cure of this may at first be attempted mechanically, by tight bandages, which press out the matter, and keep the sides in contact; but, if the disease have been of long duration, then, whatever may have been its nature at first, we find, that the suppurative action extends along the mechanical sinus, which then becomes affected with a chronic action; in which case, it becomes similar to the second species of sinus. We must, in this species, make an opening at the most dependent part, and employ the means which will be now mentioned in considering the second species, or that produced in consequence of the suppurative action becoming chronic or habitual, independent of any mechanical cause. This may take place, although the aperture have been originally in a proper place, and the matter, instead of being retained and keeping up the disease, shall have been regularly discharged. The case in which this is most likely to happen, is that in which the abscess has been very tedious in its progress, and the action has been, from the first, slow. The distinction betwixt this species, and those which remain to be mentioned, is founded upon the absence of the symptoms which they possess, and by our examination with the probe, which points out the cause and extent, and informs us whether we be near a bone. The orifice is flabby, and has the appearance of the indolent ulcer. The cure of these sinuses is to be attempted, by pressing out the matter by means of proper bandages, or by making a dependent opening, which is generally necessary, at the same time that we raise the action of the part to a proper degree, and render the suppurative action acute and vigorous; in which case, it naturally terminates in the ulcerative, and thus the part has its structure restored. This is most easily effected, by passing a seton, and applying a proper degree of pressure, diminishing the size of the seton gradually, and in proportion to the vigour of the action and the approximation toward health. When, from the situation of the sinus, we cannot pass a seton (which rarely happens in this species of sinus), injections of wine may be used frequently, and pressure applied during the intervals. When these means fail, which is seldom the case, the part should, if its structure permit, be laid open. If this sinus have remained long open, its surface, like that of the chronic abscess, becomes changed, and a coat is formed, like the cyst of a tumour. When this is thick and hard, the sinus has been called a fistula, and it has been deemed necessary to dissect out the tube; but it is in general sufficient to use the remedies which increase the vigour of the action, and make it run its natural progress; such as the seton, or a free incision, if the parts be superficial, or no considerable vessel or nerve runs the risk of being wounded.

The third species of sinus is that in which the suppurative action is kept up by the operation of some adventitious cause; such as a caries bone, diseased cartilage, or the lodgement of a foreign body; as, for instance, a ball, a splinter of wood, bit of cloth, &c. This species is distinguished by our feeling the extraneous body, or diseased bone, with the probe, and by the fungous protuberance, or papilla, which shoots out from the orifice. In addition to the method of curing other sinuses, we must here endeavour to remove the adventitious cause, which is generally very difficult to be done. If the foreign body be deep, or if the diseased bone lie deep, and the sinus be narrow, we can do little in this way; sometimes, indeed, by enlarging the external part, we can come at the foreign body with a pair of small forceps, and may extract it, or may accelerate the exfoliation of the diseased bone; but we can have no certainty of success. If, however, the sinus be superficial, which sometimes happens in caries of the tibia, &c. it ought, in every instance, to be fully laid open, and the bone exposed, and treated in the way immediately to be mentioned. When this cannot be done, we may sometimes, by conveying the proper remedies through a tube down to the bone, procure exfoliation; or may, by setons, injections, and pressure, procure a temporary cure; but, as long as the adventitious cause remains, we cannot expect a permanent recovery. It is observed, that sinuses, when they can be healed in these circumstances, break out again upon very trifling exertions, and very frequently are renewed, after a short interval, in spite of all our precautions; such as rest, warmth, &c.

A caries36 of the bone is at all times a disease which is difficult to manage, both on account of the mechanical obstacles which we have to overcome, and the slowness with which the affected parts perform their actions either of disease or recovery. The divisions of this disease have generally been taken from the appearance of the caries, and its extent. We have the dry caries, the worm-eaten caries, the spongy, or carnous caries, &c. and we have the deep and superficial. But, as the cure of these is to be conducted on the same principles in all of them, and as they are most probably different degrees of the same complaint, it will be more useful to divide them into those which affect bones lying deeply, and those which affect the more superficial bones; because these different cases are attended with very different circumstances and symptoms. The first is preceded by an abscess, which forms generally with much pain, runs its course slowly, and does not burst for a considerable time. When it does open, its sides do not ulcerate, at least universally, but a sinus remains, the mouth, or exposed part of which only, assumes the ulcerative action. The second is more rarely preceded by any abscess, but is either coeval with the ulcer of soft parts, (both being produced by mechanical violence) or it succeeds the ulcer, and is caused by it. This ulcer belongs to the third genus, and will be afterwards described.

In treating of the cure of caries, the first thing is, to determine by what means the disease of the bone may be removed; and, secondly, what modification our treatment must undergo, in consequence of the caries belonging to the first or second species. From the very earliest periods, we find the application of stimulating and corrosive remedies recommended in this disease. The actual cautery, euphorbium, mineral acids, scalding oil, the essential oils, and warm balsams, have been universally employed, and frequently alternated with rasping and perforating the bone. This proceeded from observing, that, on the one hand, mild applications had no effect, and, on the other, that the natural slowness of exfoliation was overcome by the use of these more powerful remedies. A caries of a bone is correspondent to a mortification of a soft part; and, therefore, it is impossible to restore the diseased part to health, or life. Our chief object, then, must be to prevent the disease from spreading, and to procure a speedy separation of the dead portion. The first is much less under our power than the second; for, it is most probable, that, in the majority of instances, at least of those of a simple nature, the disease, from the first, extends a certain length, affecting a portion of the bone, and that it afterwards makes very little progress. There is, however, a specific disease which affects the bone in common with the soft parts. The bone becomes rough, and suppurates; and the soft parts have a fiery appearance: This has been called the phagedenic caries. Cancer, scrophula, lues, and other specific actions, also spread after they are once induced. The second object is to be effected by such means as operate upon the vitality and action of the part, and those which act mechanically. Those which tend mechanically to remove the dead portion, are perforations down to the sound part, which we know has happened, by the bleeding which ensues; or, we may saw down this length with a trephine. We thus, by cutting off the communication of part of the diseased surface with the adjacent parts, kill it completely, sooner than could otherwise happen, and likewise stimulate the parts below to assume the ulcerative action, and throw it off. We may also sometimes be able to turn out these portions with a levator. Those which act more exclusively, by affecting the action of the part, are stimulating applications; such as heat, acids, &c. The actual cautery is so terrifying to the patient, that it is now laid aside; and it is likewise liable to this objection, that it may, by its operation on the neighbouring parts of the bone, produce disease in them. The potential cautery is more useful, and may frequently be employed with advantage, either in a solid form, as to callus, &c. or dissolved in water, and applied with a pencil37. M. Sue, in his notes to Ravaton’s Practique, &c. recommends l’eau mercurielle, or solution of mercury, in nitrous acid. By these means, the sound part below assumes the ulcerative action, its connection with the diseased portion is then destroyed, and reparation takes place. The ulcer of the bone is red, and its surface covered with innumerable granulations, which rise up to the level of the surrounding parts, after which a cicatrice is formed. These granulations in the bone are absorbed, and others more perfect are deposited in their place, until at last they become completely osseous38.

The next point which merits our attention, is the situation of the bone, and the circumstances which attend the caries. When superficial, a fungous ulcer is produced, and the modification which this situation requires in the application of the general plan will come afterwards to be attended to; the modification in the treatment which is required in sinuses has been mentioned above. It may here only be remarked, that, where the sinuses are superficial, they may be laid open, which will induce the ulcerative action in their course, and allow us to apply the proper remedies to the bone; but where they run deep, we must either allow the disease to run its natural progress, and treat the constitution according to the effects produced, or, by means of a canula, convey a piece of caustic to the diseased part, in the same way as we treat obstinate strictures of the urethra, &c. When, with the probe, we feel the bone loose, we may assist its exit with the forceps, or by enlarging part of the sinus, according to circumstances.

When these sinuses communicate with joints, and depend upon diseased cartilages, tendons, or articulating surfaces of the bones, we can do very little in the way of curing them by injections or incisions; because we cannot thus remove the disease of the joint, but may increase it. Issues placed over the joint, with rest, cleanliness, and good diet, country air, &c. are the remedies chiefly to be employed in these cases; or, if hectic be induced, and these remedies fail, we must remove the diseased part, if this, on account of its situation, be practicable. When, however, these sinuses are superficial, and depend upon tendons not immediately connected with the articulation, it may be useful to lay them open, and treat the disease of the tendons with caustic, like a caries of a bone, or with escharotics, and stimulating applications.

The fourth species of sinuses, are those where a specific action exists39, and prevents the healthy ulcerative action from forming. Of this kind is the scrophulous sinus, which is generally accompanied with a caries bone, or diseased cartilage, and, therefore, is a complicated sinus40. This is distinguished, where the bone is diseased, by a shining or polished red skin, like a cicatrix, surrounding the fungus papilla at the orifice of the sinus, or the scrophulous-looking sore which exists there. When no caries bone exists, we have no papilla, but only the diseased ulcer at the orifice. In both cases, there are generally the marks of a scrophulous habit. In the first case, we are to treat the sinus as if it were of the third species. In the second case, we are to treat it as if of the second, conjoining the proper remedies internally, as will be mentioned in considering the cure of scrophulous action. These sinuses, although healed, have a tendency to break out again, especially in the spring or summer.

The effects of the suppurative action upon the constitution, may be divided into those which are dependent upon the formation of the action, such as coldness, listlessness, &c. which are common to all new actions; and those which are peculiar to the action when fully formed. The first set requires no particular treatment, with an immediate reference to their removal; but their presence indicates the necessity of changing our method of cure, if we have not already done so. In conjunction with proper local applications, we must give light nourishing diet, with or without wine, according to the extent of the action and the weakness of the patient. Rest, and general warmth, are also necessary; but the heat ought not to be carried so far as to produce any considerable sensation, or sweating. Diaphoretics have been recommended41; but there does not appear to be any necessity for their exhibition; because the cold, and other symptoms which we intend to relieve, depend upon the state of the local action, and are only to be removed by fully forming this action. Heat will not cure this coldness, or shivering, when the action which causes it is extensive; but, on the contrary, will frequently increase it, by accelerating the formative process. The immediate effects, then, or the primary symptoms of suppuration, require no particular treatment, with a view to their own removal, but are to be attended to as marks which point out the necessity of a change of treatment, with a view to keep up the action which induces them, and to prevent it from producing bad consequences afterwards to the constitution. Sometimes, indeed, in delicate people, suppuration at this period produces hysterical symptoms, such as languor, flatulence, or sometimes starting, tremors, and hysteric paroxysms, more or less distinct. The slighter affections of this kind may be frequently removed by a little warm wine and water; the more severe, by anodynes, conjoined with aromatic waters.

The second set of symptoms, or effects, are those which have been already described under the name of hectic, the production of which has formerly been explained. This action, when slight, has been called weakness, and has been considered as dependent upon the quantity of the discharge; but, for the reasons formerly mentioned, this cannot be admitted. The cure of this state is to be attempted, by lessening the local action, at the same time that we give soups, and other articles of nourishing diet, with a moderate proportion of wine, if this do not quicken the pulse, and produce heat of the skin. Anodynes in the evening, by procuring rest, will also be useful; but none of these remedies will produce their proper effect, unless the patient respire a pure air. Bark is considered as useful in these cases; but, unless good diet be conjoined, it is not of much benefit. If, however, we give the means of increasing the quantity of vital power, bark, by inducing an action more nearly resembling the natural one, will be serviceable; but, for this purpose, it must be exhibited in full doses. It is from giving this medicine too sparingly, and in cases where other causes, tending to counteract its effects, such as poor diet, bad air, &c. are allowed to remain and operate, that bark has been brought into disrepute.

When the general action is very considerable, then the exquisite hectic is induced, and the situation of the patient becomes alarming. When the local action is simply the suppurative or ulcerative action, we may consider that the general disease is also simple, and are to attempt the cure by the remedies which have been just now mentioned. In conjunction with such local applications as tend to check the local action, we must have recourse to all those means which tend to strengthen or renew the natural action of the system in general; for which purpose, we must attend, in the first place, to all the particular functions, or individual parts; and, in the second, to the whole in the aggregate. Under the second head are included bark and wine, with moderate exercise42, and proper diet; in the choice of which, we must be directed by the nourishment which is yielded, and by the capability of digesting the articles which we employ. In general, milk, soups, and jellies, answer best. Under the first head are included such remedies as tend to promote digestion, such as steel, bitters, mineral acids, &c. although in general the bark will supersede their use. The state of the bowels must also be attended to, avoiding costiveness on the one hand, and diarrhoea on the other. The secretion of the skin must also be regulated, stopping the colliquative sweating, if possible, by getting up for some time when it commences43. Lessening the quantity of bed-clothes, for a few minutes, will also sometimes interrupt it; but when it has continued long, it can only be checked by removing the diseased action44. A full dose of the bark given before the accession of the sweat, may sometimes, by influencing the morbid action, prevent the discharge. The respiration must in particular be attended to; for, by breathing country and pure air, the action of respiration is more fully performed, and, consequently, the source of vitality is increased, and the effects of our other remedies are increased. The importance of a change of air can only be known by those who have observed how fast patients have recovered from operations when removed to the country, and clean lodgings, with well-aired beds, although before this they were daily sinking. Indeed no capital operation, which is likely to induce the suppurative action, ought to be performed, where cleanliness, and a free circulation of air, free from foetor, cannot be procured.

It is not yet discovered that any remedy has a specific power of removing the hectic, or diseased formative action, more than the local purulent one45; and, therefore, we are obliged solely to trust to these already mentioned, which have a natural tendency to increase the healthy action, or induce one nearly similar to it, and especially to a proper local treatment, by which we remove the exciting cause.

When these remedies fail, and the disease seems to continue, or increase, in spite both of general and local remedies, then we must, if it be practicable, remove the diseased part by an operation; and, in doing so, we must remember, that delay beyond a certain period is dangerous; because the general action becomes so rooted, and the strength so reduced, that recovery cannot take place. Operating in these circumstances, therefore, can only hasten death. The wound will not unite nor heal, and the general action will continue unabated.

When the local action is specific, the general one is also different from the simple hectic; and, therefore the remedies which are useful in simple hectic will not be of equal advantage in these cases, unless a specific remedy be conjoined, as, for instance, mercury prudently exhibited in the venereal hectic, dependent upon a neglected local complaint. The most frequent instance of specific hectic is the scrophulous; for the cure of which we possess no remedy which acts with certainty. Whenever, therefore, the local complaint cannot be cured, and the hectic increases, we must, if possible, remove the diseased part46; after which, the general action, notwithstanding its specific nature, most commonly declines; but the constitution still remains, as formerly, scrophulous, or even more so than before. That this is the case, would appear from the following fact: If a person slightly scrophulous, although originally sprung from a scrophulous stock, or in whom the constitutional disease seems to be disappearing, in consequence of intermarriages, &c. has, by means of a local injury done to a joint, &c. the scrophulous action excited, and consequent hectic, that person will, after cure, have the tendency to scrophula stronger in him than formerly; and the disease will even frequently be communicated to his children with its original violence.

Of the Treatment of the Ulcerative Action.

Suppuration is a natural termination of inflammation; and the ulcerative action is invariably induced by the suppurative, unless this remain chronic. The ulcerative action is to be considered as in part a restoration of the natural one; for we find, that it produces a restoration of the structure, granulations being formed by the vessels which formerly supplied the organic particles, whilst the interstitial vessels still yield a morbid fluid, called pus; but this they cease to do, whenever they again are placed in the natural situation; that is to say, whenever they become covered with the granulations, or are rendered interstitial. In proportion, then, as granulations are formed, a certain number of vessels are rendered interstitial, so that the discharge gradually diminishes, until at last it ceases; for, when we come to the formation of a cuticle, we have very few interstitial vessels left, the skin having naturally few. At this time, the one set of vessels having completed their action, and the part being restored, the other also resume their action, and a thin exhalent fluid is thrown out by the new cuticle, which keeps it soft and moist, and which is the natural insensible perspiration. The action of the two sets of vessels, then, is dependent on each other; and, whenever one is diseased, the other becomes also more or less so.

GENUS I.

Of the Healthy Ulcer.

From these remarks, as well as from those which were formerly made, it will appear, that a healthy ulcer has a natural tendency to heal, and that we ought only to be careful not to interrupt the natural progress, nor allow the action to flag.

In this genus of ulcers, the bottom of the sore seems to be paved with a number of small fleshy points, with minute interstices betwixt them, or surrounding their bases. These are of a red colour, with a slight shade of the purple, and are wet with a yellowish fluid, which is called pus; but which must of necessity differ from the fluid yielded by suppuration. This separates freely from the surface, when it is wiped or touched with a sponge, and then the granulations may be distinctly observed47. The margins are smooth, thin, and a very little rounded, that is to say, are almost imperceptibly raised above the granulations, a circumstance which is essential to this ulcer, because, were they both on the same level, it would show, that the cicatrizing process did not go on properly; for, whenever the granulations rise to the level of the surface, they ought instantly to form skin. This cicatrix, which extends gradually from the circumference to the centre, is of a pale red colour; but the integuments immediately beyond it are white, and of the natural appearance. Sometimes, from a slight deviation or imperfection, one spot of the disk rises to the level sooner than the rest; but, in this case, it immediately skins, and the cicatrix extends from this in the same way as from the circumference, until they both meet. The sore is free from pain, the only sensation being a slight degree of smarting, or itchiness.

The treatment of this ulcer is very simple; for, in most cases, it is only essentially necessary that we prevent the operation of hurtful causes. We defend the part, by covering it with a soft pledget of lint, and keep it warm. When the cicatrization has commenced, it may be assisted by using an ointment containing any harmless powder, in such a proportion as to form a paste or scab upon the part48, by which we afford an artificial covering, which remains in close contact with the granulations; and, by thus bringing them nearly into the same circumstances as when skin is formed, the cicatrizing action is accelerated. The same effect is sometimes produced, by allowing the pus to form a scab over superficial sores, by exposing them to the air, without any covering.

Dry lint is a very useful application; but, as it is apt to stick to the granulations, and tear them, when tender, it ought always to be well moistened before removal, which should be attempted slowly.

Mild ointments, such as the simple cerate, are frequently employed; but they must be free from all rancidity, otherwise they fret the skin, or injure the sore. In general, they are less useful than dry lint. When we do employ them, they ought to be applied only to the granulations and cicatrix, and not to the sound skin. More frequently we use these ointments spread on a pledget of linen, to keep the dry lint on the sore.

Poultices are also recommended in these cases; but they possess no peculiar advantage, and are apt to make the part feeble, and more likely to break out again.

Moderate pressure, by keeping up the action, is generally of service; but it is still more necessary when the action begins to flag, or becomes stationary. In this case, a compress ought to be placed over the sore, and the whole member rolled firmly round with a cotton bandage or, what will be still more useful, the part should be encircled with strips, spread with adhesive plaster, in the way which will afterwards be mentioned. Pressure acts by taking away the condition of vacuity; it forms an artificial covering and interstices for the superficial granulations, by which the natural process of forming granulation and skin is greatly assisted. The parts are, in this way, not only more quickly formed, but also in greater perfection; and their powers of action are greater. The cure is therefore more permanent, and the part is not so apt to die, or ulcerate again, as when healed with simple dressings.

This practice, which is useful in ulcers which from the first are healthy, is still more necessary in curing those which were formerly diseased, but have now become healthy; because, in them, the action is still more apt to flag.

The healing of large healthy ulcers which succeed to wounds, &c. will also be much hastened, if we artificially diminish the size of the cavity, and procure contact. Whenever one part can be brought in contact with another, it ought to be done, if the figure and functions of the part be not thereby injured, or if pain be not produced by doing so.

The older authors, from a mistaken theory, never allowed the action to proceed uninterrupted, or never co-operated with it in a rational manner. In every ulcer, it was necessary, first, to digest, or suppurate it, which was done with turpentine, or basilicon; next it was to be deterged with turpentine, mixed with yolk of eggs, or by the red precipitate; then it was to be incarned by sarcotics, such as tincture of myrrh and aloes, balsam of Peru, frankincense, &c.; lastly, the surface was to be dried into a callus, with dragon’s blood, white-lead, chalk, &c. These plans have, however, been long laid aside; but some practitioners still advise the use of styptics and spirit of wine to produce a cicatrix; they forget, however, that skin is formed by a different process than corrugation.

The diet ought to be good, in all cases of ulcers; but spiritous liquors, and the irregularities of life, must be avoided.

In ulcers of the legs, if pressure be employed, rest is not absolutely requisite; but, if this be not used, no cure can be obtained, if the patient walk about. Even if the adhesive plaster be applied, we ought not to allow of so much motion as to produce fatigue, or any uneasiness in the sore.

The treatment, then, of this genus of ulcers, may be comprised in two aphorisms.

First, When the action is, from the first, healthy and vigorous, and is continuing so, all which is essentially necessary, is to defend the part, and prevent the operation of any cause which might injure the action, such as cold, too much heat, mechanical irritation, &c. This may be done, by applying a bit of dry lint, or a rag spread with simple ointment, and wrapping the limb round with a flannel roller. But, if the action begins to flag, as it often does in large ulcers, or if the process become stationary, we must then indispensibly have recourse to gentle pressure.

Second, When the action has, at any one period, been diseased, or too low, but has been restored to a proper state, we must of necessity continue gentle pressure, and treat the sore as if the action were stationary, although it may not be so.

GENUS II.

Of the Indolent Ulcer.

In this genus, the action is diminished, and, consequently, rendered imperfect and diseased.

Indolent ulcers, like those of the next genus, are divisible into two species: First, that in which both parts of the ulcerative action, namely, the granulating and purulent, are equally diseased, and equally imperfectly performed: Second, that in which one part is more affected than another49.

The first species is distinguished by the following symptoms, which appear in greater or less degrees, according to the diminution and imperfection of the action.

The granulations are pale, and imperfectly formed, partaking less of the firmness and organisation of the healthy fleshy granulations in proportion to the affection of the action. They are obtuse, and scarcely at all elevated; and, therefore, the surface loses its doted, or red pointed appearance. The discharge is thin, and of a whitish colour, at the same time that we frequently observe isolated spots of lymph interwoven here and there with the imperfect granulations. Although these granulations are said not to be elevated, yet the surface often exhibits a species of fungus; but the individual granulations are not elevated, or pointed. This fungus never rises higher than the twentieth part of an inch above the level of the surrounding skin50, and often appears only at particular parts of the surface. It is pale, and somewhat of a gelatinous appearance. The pain is trifling.

In more advanced cases, the whole disk is covered with a thin layer of lymphatic substance, which adheres firmly, and gives the idea of a thin pellicle being thrown over the granulations, which are seen imperfectly and irregularly through it. The discharge is generally thin, like serum, and considerable51. The edges are hard and tumefied, sometimes of a light purple colour, at other times white52. The surrounding integuments are also hard and thickened, at least in old ulcers, and the veins are generally more or less varicose.

These appearances vary in degree from the soft pale surface, and thin whitish purulent discharge, with slightly thickened edges, to the state now described. The pain, when compared to the size of the ulcer, is not considerable.

This genus may occur, in a slight degree, in recent sores, from neglect, &c.; but it is chiefly after ulcers have been of long standing, that they assume these appearances in the greatest degree. They may then be said to have become chronic, or habitual; and, in many instances, it is absolutely impossible to restore the action to its natural state, and produce recovery53.

The second species is distinguished by the paleness and imperfection of the granulations, whilst the discharge is tolerably good; but it never can be equal to that of the healthy ulcer; because, when one part of the action is affected, the other is also more or less affected. This species does not require any more particular observation or remark, because it is to be treated exactly as the first, of which it is often just a slighter degree, or a forerunner; for it is frequently the first change which takes place in a healthy ulcer. When it becomes diseased, it does not continue long; for both parts soon come to suffer in the same proportion; in which case, the ulcer belongs to the first species. For this reason, we never find old ulcers belonging to this species.

Chronic ulcers sometimes induce a disease of the bones, &c. below; but, in this case, they generally are converted into a different genus. They also come naturally, in consequence of the great imperfection of their action, and the consequent want of power, to act beyond the due proportion betwixt action and power; and, therefore, most ulcers of this genus come at last, if neglected, to belong to the next.

The most effectual remedy for these ulcers is pressure. This has been long employed, by means of tight rollers wound round the limb, or by the laced stocking. But, of late, a more effectual method has been proposed, namely, a bandage of adhesive plaster, which applies itself closely to the surface, and produces a state of artificial contact and covering. This has been recommended by Dr. Darwin in the form of a many-tailed bandage, and by Mr. Baynton in the form of strips, wrapped round the limb. The following is the method of applying them: A strip of adhesive plaster, about an inch broad, and so long as to encircle the limb and cross at each end, is to be warmed, and the middle of it applied to that part of the limb which is exactly opposite to the sore; both ends are now to be brought forward, and one of them laid tightly over the under part of the sore (if it be so large as not to be covered with one strip), whilst the other is brought firmly over this from the opposite side, and doubled down upon it. The ends of the strip thus fold over each other at the ulcer. Another strip is then to be applied to the part of the sore contiguous to this which is not yet covered, and so on in succession, until the whole be covered. This is the best way of applying the strips, if the integuments be firm; but, if they be loose and yielding, it will be useful to push forward the loose skin from behind, with the strips, as we bring them forward; and, instead of laying down first one end, and then the other over it, make the two ends cross each other at the same time, and lay them down upon the skin, and not on each other, the under end covering the lower part of the sore, and the upper the part next it. The same strip, therefore, covers two portions of the surface, whereas, in the first way, it covered only one; but, in this case, the strip must be longer, as it must fairly cross the ulcer on each side, and be retained by sticking to the adjacent skin. When the ulcer is deep, the strip will press only on the margins; and, therefore, it will be useful to fill up the surface with a fold of soft lint. A thin cotton roller is now to be wound firmly round the limb, beginning at the extremity, and continuing the bandage to the next joint above the sore.

By this contrivance, we obtain a firm covering to the granulations, and bring a substance in contact with each individual. We then restore, as it were, the natural state of the parts, each granulation having a substance in contact with it; and a slight interstice is left between each, owing to their pointed structure. They become, therefore, similar, in this respect, to the organic particles of internal parts; on which account, healing goes on more quickly, and the organic particles, or granulations, are deposited in greater perfection, and with greater powers of action; for the unusual and morbid condition of exposure and want of contact is now removed. The same circumstances promote cicatrization, when the granulations have risen to a proper height. This is more evidently seen in the cure which is effected of the smaller ulcers, by dusting them with chalk, &c. or dressing them with an ointment made thick with some mild powder, by which a scab, or covering, is formed, which operates clearly independently of pressure. Pressure, applied with this view, ought to be moderate and permanent, and may be used with utility in almost every case of solution of continuity, however healthy the action may be. But, besides being of use in this way, pressure also produces a second set of effects, by mechanically exciting action in the part to which it is applied. Applied to the skin, it increases the cuticular action, and the skin is formed thicker. Applied to a weakened part, it increases the natural action of that part, and strengthens it: This is seen in the instance of debilitated muscles, &c. But, if the pressure be too great, then a morbid increase of action takes place, which even goes the length of inflammation, if the pressure be considerable; and this inflammation is either strong or weak, according as the pressure has operated; for, if many vessels be obstructed, as is commonly the case, then the power of the part is injured, and the action is weak; or, the same happens if pressure be applied in any manner to a weak part, or if the constitution be weak; as, for instance, from previous disease.

Pressure, applied to a part, increases in particular the functions of absorption and deposition. If moderate, these functions are moderately increased, and the structure of the part continues either the same, or it augments in size, as we observe, in the effects of walking, on the skin of the feet; but, if the pressure be greater, then these functions are morbidly increased, the particles are deposited imperfectly formed, and are as quickly taken up. The structure is therefore destroyed, and a vacuity formed. These effects are produced more easily upon diseased than healthy structures; because their powers of acting, and sustaining action, are less. Friction is in this respect similar to pressure.

From these remarks, we may understand the mechanical utility of pressure in the cure of ulcers; for, when in a proper degree, it causes the absorption and destruction of the callous edges, or diseased substance, and likewise makes, if moderate, the diseased granulations be taken up, and more healthy ones be formed. We may likewise perceive, that, if the degree be too great, the action will become of an inflammatory nature, and injury will be done. We are therefore frequently under the necessity of counteracting this hurtful effect; for, the degree of pressure which is requisite for answering the first intention in old sores, or inducing action, in consequence of bringing the granulations or particles into the natural state of being in contact with some body, or covered by it54, is often attended with such mechanical irritation, that the one effect would destroy the other, unless we kept the action within due bounds, by applying cold to the part. In healthy ulcers, the pressure necessary to produce its first set of effects, or to accelerate healing, by producing contact, is so trifling, that no counteracting effect takes place by the production of the second set of effects; and, therefore, no cold requires to be applied: But, in old ulcers, the pressure must be greater; and, therefore, cold water must be constantly applied to the bandage over the sore, by means of a sponge. We thus indeed lessen the effects of pressure on the absorbing system, and, therefore, the callus will be longer of being destroyed; but we, on the other hand, prevent the action of the granulations from being rendered morbid.

The good effects of pressure, applied in a degree proportioned to the effect which we wish to produce, and to the state of the sore, are so universal, that it is unnecessary to give any examples of its success and utility. But, at the same time, it must be observed, that in old ulcers, and even in many of a more recent date, which have been much neglected, no application whatever will produce an uninterrupted cure; for, after some time, it ceases to produce the same effect upon the action. The part seems, by continuance, to be less acted on by the agent; the action is less affected, and slowly returns to its former state of imperfection. It is therefore necessary, either that we from time to time increase the power of our application, or vary our remedies, whenever the process becomes stationary. The latter is generally the most effectual way; and the remedies which we alternate with the effects of pressure, are those of what have been called the stimulating kind; but which of the individuals of this division ought to be employed, cannot always be determined, because one succeeds better in a particular instance than in another. It would, however, be of much importance, to ascertain which in general operated most effectually; because, if we employ one which does no positive good, we sustain positive harm; for the action is allowed to persevere in a retrograde process. I, therefore, paid particular attention to the operation of these applications, in the patients who were under my care in the Glasgow Infirmary.

Heat is found to increase almost every action; and, therefore, in indolent ulcers, it is sometimes of use, especially for a few days after we begin the management of the sore, as it paves the way for the action of other agents, by beginning a change of the action. Poultices are the vehicle by which it is most frequently applied, and answers, in general, better than other forms. Fomentations are much used by many practitioners, who employ decoctions of different kinds of vegetables; but they have no superiority over poultices. Dry heat was used by M. Hevin, who held ignited charcoal near the sore; and it is sometimes of use to repeat this practice betwixt each dressing.

Electricity is of little service; because it cannot be constantly employed; and, therefore, its operation is only temporary.

It is worthy of observation, that although this kind of ulcer may be sometimes completely cured by the use of heat, that yet the action is not so perfect, and consequently the structure and power of the part is weaker, than when stimulating dressings are employed. Exercise, or any other cause, is therefore more apt to injure the part afterwards, and make it again break out into an ulcer.

The red precipitate, mixed with resinous ointment, in the proportion of a drachm of the former to an ounce of the latter, is a very useful dressing; but the ung. hyd. nit. mixed with four times its weight of hog’s lard, forms an ointment which is still more generally useful.

Ten grains of the cuprum ammoniatum, rubbed up with an ounce of basilicon, or simple ointment, is sometimes useful, but cannot be depended on. The same may be said of an ointment composed of an ounce of ung. simplex, and ten drops of the oil of cloves, or of savin.

Cloths dipped in the aqua zinci vitriolati, or the solution of cuprum vitriolatum, diluted with water, so as only to smart moderately, are likewise of service, but not so frequently as weak solutions of the nitrates of silver, zinc, copper, bismuth, and many other metallic salts, such as muriate of mercury, &c.

Solution of common salt, or of nitre, of such a strength as to produce a moderate smarting, are of temporary advantage, but will not continue their effect long. Indeed all solutions of saline substances, whether alkaline or metallic, are most useful when applied only for half an hour at a time, when the sore is dressing.

Mixtures of Thus, elemi, turpentine, canadine balsam, &c. with wax, or oil, have no advantage over the common ung. resinosum55.

The bile, either by itself, or diluted, or mixed with yolk of eggs, does not seem to be of much service.

Lemon juice, or the mineral acids, particularly the nitrous, diluted so as to be of equal strength with the juice, are frequently of service56. Port wine is also an useful lotion.

Infusion of Cayenne pepper, in vinegar, added to water, in such a quantity as to smart, forms also a very useful application.

Of all these remedies, the ointments composed of the nitro-metallic salts, particularly the mercurial, are most generally useful: And the cure seems to be accelerated, by applying cloths dipped in weak solution of metallic salts, or weak acids, during the intervals of dressing. Whenever these applications fail, they must be dropped: And those which fail first, and soonest, seem to be the watery, or fluid applications; and, next to these, the simple resinous ointments.

These remedies generally produce their effect first at the margins. When this takes place, we must diminish the strength of the application at that part, in proportion to the activity of the action, which is marked by the redness and pointedness of the granulation, and the cicatrizing state. The circumference, and the rest of the surface, must, in this case, be dressed with different strips of linen, spread with different ointments. Soft linen, spread with simple cerate, or dry lint, which is preferable, should be applied to the cicatrix, and cicatrizing granulations, whilst a stimulating substance is applying to the rest of the surface.

When the surface is obstinately diseased, or the action very torpid and imperfect, caustic has been applied; but, although I have often used it, and even applied cloths dipped in solutions of metallic salts, so strong as to form an universal eschar, or slough, yet no benefit whatever was derived; for we do not thus change the nature of the action, but only remove a layer of the surface, and leave that below in possession of the same mode of action with the former. Caustic is more useful, when applied to callus edges; but even these are more effectually removed, by remedies which act more permanently, and gradually, particularly by pressure. The ancients used to extirpate these with the knife, but few will consent to its use. It is indeed more speedy and effectual than the caustic; but, unless the action be afterwards properly supported, it will be of no permanent service.

The hard and thickened state of the surrounding integuments, in old ulcers, is best moderated by pressure; but this must be long continued.

Varicose veins, were, by the ancients, considered as canals running into the sore, and furnishing the discharge; but, when we consider that these varices frequently occur without any ulceration, or discharge, the opinion must be abandoned. In such cases as occur alongst with ulceration, it will be more natural to consider the affection of the vein as a disease dependent originally on the ulcer, and induced by it, in the same way as the structure and functions of other neighbouring parts are changed and impaired by the continuance of a tedious and diseased ulcerative action. This state of the vein being once induced in any part of it, and even in a slight degree, two consequences follow: First, from the power or property of the vein being impaired, the blood is not duly propelled, but circulates slowly, and cannot overcome readily the weight of the blood above, which presses more powerfully, in consequence of the valves being rendered imperfect by the distension of the vessel. The disease, therefore, gradually increases; for, every day, the power of acting properly diminishes, at the same time that the mechanical necessity for acting, or the resistance of the column of blood increases. On account of the dilatation of the vessels, and the morbid or abortive effect to propel what they are unable to do, pain is produced, in the course of the varix, whenever the legs are kept in a dependent posture, or exercise is used. This pain is confounded with the uneasiness arising from the ulcer; and, therefore, these ulcers are said to be painful, and to be attended with pain in the course of the veins.

The second consequence is, that, as the veins which are more immediately connected with the ulcerated part, are diseased, and do not perform their part in the circulation properly, the functions of the part must be still more injured, and the varix, which originally perhaps was produced by the ulcer, comes in its turn to act on the sore, and prevent its healing; for the vein not acting properly, and conveying the blood fully, the action at the capillaries must be injured, and the artery and vein cannot act healthily. If this be the case, the power of forming granulations must be impeded, and these never can be deposited in the necessary degree of perfection.

Two modes of cure have been proposed, the one palliative, and the other radical. The first is effected by means of rollers, or bandages, which prevent the vein from being distended, and, therefore, enable it the better to carry on its circulatory function. In this way, we prevent, to a certain degree, the hurtful operation of the vein upon the ulcer, and are often enabled to heal it up. But, as we do not thus restore the vein to its natural powers, unless in young people, who continue the support or pressure for years, we can obtain no permanent cure of the varix; and very frequently the parts again ulcerate; because, whenever the pressure or support is withdrawn, and the patient walks about, then the function of the part becomes affected, the organic particles are not deposited in the same state of perfection, and the action which is induced by exercise causes the destruction of these granulations; or even the very circumstance of their being formed imperfectly is sufficient to produce their destruction, and the opening of the part; for all parts which have been formerly ulcerated are most ready to assume this action again, and the organic particles of that part are less perfect, and less able to bear action.

The second is obtained, by obliterating the diseased vein, or interrupting its communication with the trunk above, by which we make the blood take a different course, and be transmitted by healthy veins. If we now cure the sore, we find, that the same effects are produced as if we used permanent pressure; and, therefore, the functions of the part are more properly performed, and the organic particles possess greater power of acting, and sustaining action. The older surgeons proposed to effect the radical cure, by tying the vein at the two extremities of the diseased part, and cutting out the intercepted portion, or by laying it open, and digesting it, as they said. This, however, was, as they confess themselves, very seldom submitted to in ulcers of the legs; and was rather inserted to complete their treatises, than from a belief that the operation ought to be insisted on. Of late, it has been proposed by Mr. Home, to tie only the upper extremity of the diseased portion57, by which adhesion takes place at that spot, and the circulation is there stopped. The pressure of the blood above is thus taken off, and the blood from below must circulate, in a greater degree, through vessels which are better able to perform their functions; and, therefore, the actions of the capillary vessels, whether nutrition, absorption, or conversion of the blood from arterial into veinous, must be more naturally performed. After the veins are tied, they gradually become smaller; for the pressure being permanently removed, the diseased veins can more fully propel their blood by lateral branches, at the same time that they receive less blood, more going by other vessels.

It is a curious circumstance, that although ulcers may have remained in an indolent state for many years, and have become almost habitual, that yet, the cause of the indolence being removed, they recover their powers rapidly, and with very little assistance. Thus, when a varix, which originally was produced by the ulcer, reacts on the sore, and prevents it from healing, we find, that if this cause be removed, the ulcer frequently heals quickly, owing to the sudden removal of a principal cause of indolence, although a similar ulcer, without varices, would not be cured by the same application in the same time; because then all the usual causes of indolence would still remain to be removed, or their effects counteracted; but, in this case, having suddenly removed one great cause, the action rises so much, that it can overcome the rest, although, without this alleviation, the healing process would not be commenced, nor continued. It may be useful to attend to this circumstance in every case of indolent ulcers, whether attended by varices or not; because, if we can remove any particular cause, we do much toward producing a cure. Thus, callus edges, and diseased, or thickened integuments, &c. although originally dependent on the ulcer, yet react on it, and prevent it from healing. If, then, by pressure, or otherwise, we remove these causes, we accelerate the cure.

As an instance of the good effects of tying varices, I shall transcribe the following case from Mr. Home’s Observations: “A man, sixty years of age, had, for many years, gained his livelihood by going on messages, having been rendered unfit for any more laborious employment by a large ulcer on the left leg, just above the inner ankle. The complaint was of twelve years standing: It had been sometimes much better than at others, but had never been well during the whole of that period. In the year 1792, it became so bad as to confine him entirely. It was at this time I first saw him. Upon examining the limb, the veins were extremely large, and varicose; and the trunk of the vena saphena, at the knee, appeared almost the size of the little finger. The size of this vein led me to the idea of taking it up at that part, with a view of relieving the lower branches from the pressure of the blood, which I believed to be the cause why the parts remained weak, and the ulcer could not be healed. I explained my opinions upon this subject to the patient, and told him, that, if he thought it worth while to try it, I was very ready to do it for him. The man’s desire to get well was such as to induce him to embrace the offer of any mode of treatment which afforded the smallest chance of it. The vein was taken up in the way that I have mentioned: He complained of very little pain, no improper degree of inflammation was brought on by this operation, the ligature came away in nine days, and in fourteen the wound was healed.

“The ulcer upon the leg was dressed with dry lint; it put on a better appearance on the second day after the operation; on the fourteenth it had diminished in size one half; and in twenty-eight days was completely healed. He was also freed from a pain in the course of the veins of that leg, to which he had been subject for many years, whenever he used any exercise.

“He returned to his business of carrying messages, and called upon me a year after, perfectly well; his leg having continued sound.”

Issues have been proposed for the cure of this genus of ulcers; but, upon the principles which have been already mentioned, it must be evident, that they can be of little or no service; and, I am sure, that I never saw the smallest influence exerted by them over an ulcer. They are useful, however, after the ulcer is healed, by keeping up a secreting action, diminishing the risk of apoplexy, &c.; but then they ought never to be introduced until the sore be nearly healed, or until we have reason to suppose that the sore will heal, and that they will be required.

The treatment of this genus of ulcers may be comprised in the following aphorisms:

First, When the action of an ulcer becomes too low and imperfect, pressure is the best remedy for restoring it to its proper state, and for accelerating the cure.

Second, Whenever this ceases to produce any farther effect, or the action relapses, and begins to go backward, we must lay aside the pressure for a time, and dress the sore with some of the stimulating applications above mentioned, particularly the nitro-mercurial salts; and these, in their turn, must be laid aside, when they cease to produce a good effect, and the pressure be again had recourse to.

Third, When we use stimulating dressings, we must attend to the effects which they produce on different parts of the sore, and dress these differently, according to their condition. We must likewise proportion the strength of application to the state of the general action. Our remedies ought to smart most when the action is most torpid, and the smarting ought to continue longest; but, when the action has begun to be more perfect and vigorous, the same application will often be too strong.

Fourth, We must, in conjunction with this general plan, attend to particular morbid structures, which may be produced by the particular state of the ulcer, and which may react on it. The chronic thickness and hardness of the integuments, are best removed by pressure, and gentle frictions; but the restoration of the natural structure is very tedious. Callous edges are likewise best removed by pressure. When this fails, caustic must be repeatedly applied. Varicose veins may be palliated by firm bandages, but are, in general, after they have continued long, only to be cured by an operation.

Fifth, When chronic ulcers can be healed, it is useful to form an issue, in order to keep up the accustomed secretory action; but these issues have little effect in advancing the cure.

GENUS III.

Of the overacting Ulcer.

This genus comprehends two species: First, that in which the granulating, or purulent process is morbidly increased, or the two parts of the ulcerative action, the granulating and the purulent, do not correspond, or bear the same proportion to each other that they do in a healthy ulcer: Second, that in which a state of general acute overaction takes place, both parts of the ulcerative action being equally affected, and rendered diseased.

For the illustration of the first species, I may remark, that there are some actions performed by particular parts of the body which are apparently simple; but there are others which are complicated, and consist evidently of different parts, which, in the aggregate, form a peculiar action, but which action may be modified according to the degree in which these different parts exist. Thus, there are various parts which, when taken together, form the inflammatory action, heat, redness, swelling, &c.; but these may, in certain cases, exist in different proportions. The ulcerative action is a complicated one, and consists of the secretory and organising action, or the purulent and granulating. These, in a healthy ulcer, bear a certain relation to each other, and are at all times so connected, that, when one part is injured, the other is also affected; but the one part may be affected more than the other. In the indolent ulcer, or that in which the action is too low, both parts are most commonly (at least after some time) equally affected, and a state of universal diminution, and consequent imperfection, takes place; but, in the beginning of this state, that is to say, when the healthy ulcer is first becoming diseased, and when the unhealthy condition has made little progress, it is not uncommon to observe an inequality in the action, or the granulations more affected than the discharge. In this genus of ulcers, however, the inequality is more striking, and frequently more permanent.

It is worthy of remark, that though the granulating action may be increased beyond the purulent one, that yet the purulent one never exists in a state of overaction without a correspondent affection of the granulating action; in which case, very different effects and symptoms are occasioned, and the second species of overacting ulcers is produced.

The first species has generally been described under the name of the fungous ulcer, or ulcer with hypersarcosis. The granulations are soft and indistinct. They are imperfectly formed, and, therefore, do not possess the pointed appearance which they exhibit in health; nor have they equal powers of action, nor longevity. They are formed quickly, and rise to a greater or less height above the level of the surrounding skin. The margins are generally soft, tumid, and of a dull red colour. The discharge, if there be no carious bone, is tolerably thick, and of a white colour, and not in greater quantity than would be yielded by a healthy ulcer of the same size: The quantity is even sometimes less. The pain, unless when a bone is diseased, is seldom considerable. This species admits of two varieties. In the first, the granulating process is increased, in consequence of some affection of the action, which is independent of any mechanical cause. In this case, the fungus is generally pretty firm, but commonly pale, and the discharge tolerably good. In the second variety, the granulating process is increased, in consequence of some mechanical irritation underneath, such as a piece of carious bone; and, in this case, the fungus is softer, and less firm; it is of a redder and more lively or fiery colour, and is sometimes covered, in particular parts, with spots of lymph; it bleeds upon the slightest touch. The sore is generally painful, and the discharge thin, serous, and of a foetid smell, whilst we can frequently perceive at least one small foramen on the surface which leads down to the bone, and through which it may be felt to be rough. Out of this is discharged a thin matter from the bone, of a brownish colour, somewhat like soup, and more or less different from the discharge from the rest of the surface. These luxuriant granulations, however, must not be confounded with those which, at a later period, come from the bone itself, after it has begun to ulcerate. These are generally of a more florid red colour, though sometimes pale, and rise up either through chinks of the bare caries, or from such portions as are denuded by a previous exfoliation. They have, in general, a more pointed appearance than those which arise from the soft parts, so that, in many cases, the fungus resembles the surface of a strawberry, being rough. This variety may be induced quickly, the bone being injured, at the same time that the soft parts are affected; but, at other times, and perhaps more frequently, the bone becomes diseased, in consequence of the continuance of a simple ulcer immediately over it; as, for instance, on the tibia. In this case, the ulcer, which perhaps was formerly indolent, now changes its nature.

The second species exists in various degrees, and its symptoms admit of modification from the previous state of the ulcer. Sometimes an ulcer, although previously healthy, has its surface excited into a state of overaction, by exercise, or other causes. In this case, the sore becomes painful, and the granulations assume first a kind of light crimson colour, and then a brownish hue, from a species of mortification. They do not indeed become gangrenous, and slough, but they approach to a state nearly resembling death, and are absorbed. The edges are slightly erysipelatous, and the discharge watery. This may be called the first degree or stage of the disease; and the ulcer frequently recovers soon from this, and reassumes its healthy condition. But if it be neglected, or the injuring causes still continue, the state of overaction is increased, and becomes more perfect58; that is to say, the action which was injured in its different parts, and rendered unconnected by the incipient or new condition, becomes more completely and connectedly performed in its different parts, in an increased degree. The overacting state, which, in the first stage, took place, perhaps only for a few hours, or at least if it continued, did not rise to any great degree, or receive an augmentation in this stage, continues with violence, and generally with exacerbation. The granulations are absorbed almost as soon as they are deposited; because, owing to the overaction of the part, they are very imperfectly organised, and possess very little life and power of supporting action59. They evidently appear to be in a state of overaction; for they are fiery, and their colour, whether it be red or brownish, is bright or clear, and quite opposite to the dull hue which even the same colour may have in a different kind of sore. These bleed upon the slightest touch; on which account, the discharge is generally bloody. The margins are red and ragged, as if they were bitten by a mouse; and they are evidently in an ulcerating state. The surrounding skin is hot and erysipelatous, the discharge is thin and serous, and the pain great, generally somewhat of the burning kind. This sore, from the destruction of the granulations, and the propagation of a morbid degree of action, spreads as long as this condition continues; but the progress, as long as the ulcer belongs to this genus, or as granulations are formed, is not very rapid.

It not unfrequently happens, that, after a sore which has been indolent has begun to heal, it, from fatigue, or some less evident cause, has a state of overaction induced, in which case, different appearances are exhibited, according to the previous state of the sore. If it has begun to form a natural cicatrix, this gives way, the surface becomes livid, the discharge thin, and the pain considerable. A thin slough of the granulations is then generally formed, and comes off in portions mixed with the discharge. If this state be not checked, it frequently comes to exhibit the acute symptoms of the overacting ulcer which was last described. More frequently, however, it occurs when the sore is still indolent, and not in the healing state, and when the edges still remain callous, and the granulations foul and unhealthy. If, at this time, a disproportionate, or overaction be induced, by exercise or otherwise, we find, that the surface becomes dark and sloughy, the granulations flat and indistinct, the discharge is increased, and the margins become tumid, and of a modena colour, whilst the surrounding integuments are of a dull red mottled colour, or erythematous; and the foot, if it take place in the leg, is frequently cold, and the pain darts down to the toe.

This state is not unfrequently produced in old ulcers, by a disease of the parts below60, which has been induced by the long continuance of the ulcer, which renders the bone carious, if it lie immediately under it (in which case, the first species of overacting ulcers is produced); but, at other times, by the sympathy of association, a diseased formative action (owing to the diseased formative action in the ulcer, or the imperfect granulations which are formed) is induced in the neighbouring parts, the muscles become pale, and have less of their fibrous texture, or the bone becomes rough, or pointed, like shagreen, and also becomes thickened, but without any appearance of caries. This diseased condition of the parts reacts on the ulcer, and induces overaction.

This state of overacting may also be induced in old ulcers, without any malformation of the parts below, but merely in consequence of continuance; for, after an ulcer has remained long indolent, it comes to act so imperfectly, that it naturally goes beyond its power. This may be said to be a spontaneous change, or conversion of one genus into another.

We have then two varieties of this species: First, the state of overaction induced in an ulcer which was previously healthy; and this admits of two stages, the incipient and confirmed: The first sometimes consists only of one short paroxysm: The second continues for a longer time, and generally depends upon the neglect of the first attack. Second, the state of overaction induced in an ulcer which has previously been indolent; and this admits of two subdivisions, which arise from the condition of the ulcer at the time of its overacting, namely, whether it have been healing and cicatrizing, or the edges have been callus, and the action imperfect and morbid.

The observations on the cure of this genus of ulcers must naturally be arranged under the different species and varieties of these ulcers.

In the first variety of the first species, our object is to remove the supernumerary, or fungous granulations, and to replace them with others, which are formed more slowly, and in greater perfection.

Pressure, applied in the manner already explained, is one of the most useful remedies in this variety, and ought always to be tried first. The luxuriant granulations are quickly absorbed, and the succeeding ones are rendered more compact and healthy, and the cicatrix begins to be formed. If, however, we apply pressure in this, or indeed in any sore, to such a degree as to produce its specific effect, we must counteract its irritation by cold. If we do not, this sore is frequently converted into the second variety of the second species of this genus.

Caustic, and escharotics, have been sometimes applied to these sores; but they only remove a layer of granulations, without affecting the formation of the succeeding ones so much as some other remedies.

Stimulating applications are more useful; for, as they act more slowly, they produce a greater influence on the action.

The cuprum vitriolatum, mixed with simple ointment, in the proportion of a drachm to the ounce, is frequently serviceable; but the ung. hyd. nit. is still more useful. One drachm of this may be mixed with an ounce of hog’s lard and a scruple of camphor. Red precipitate, mixed with resinous ointment, is also often of service.

The application of powdered rheubarb is recommended by Mr. Home, and is frequently of service.

Lotions of port wine, solutions of white vitriol, or rose water, containing as many drops of l’eau mercurielle61 as will make it moderately pungent, may be usefully applied before the dressing.

Poultices seem to increase the diseased state; and mild dressings do not counteract it, but allow it to go on.

The second variety is only to be cured by removing the caries bone; but the same remedies which are used in the first variety may be employed here, as palliatives, or the means of preventing the ulcer from becoming worse. By a continuance of these applications, in cases of slight caries, a cure may, after some time, be obtained; for the thin layer of diseased bone, either comes away in fragments through an opening in the ulcer62, or it is sometimes absorbed. This last event, the absorption of the bone, is particularly induced by pressure, applied by means of the adhesive plaster; and, therefore, where the disease is not extensive, it is always proper to have recourse to this; but if, upon trial, we find it to fail, or to convert the sore into the second species of this genus, which it sometimes does, we must omit it.

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

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

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

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

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

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

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

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

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

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

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

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

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

R. Ammon. HepatizatÆ63 guttas decem.
Aq. Font. uncias octo.

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

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

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

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

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

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

In this sore, anodynes are to be freely employed internally; for, given sparingly, they do no good64.

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

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

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

The application of the powder of bark to these sores is sometimes, but very seldom, of service65.

A poultice, formed of decoction of camomile flowers, opium, and charcoal66, is frequently of use, and should be employed when the laudanum and camphorated spirit fail. This should be applied cold.

In the second division, the fermenting poultice67 is often of service; but it must, like all other applications, be continued no longer than the state which it was intended to remove remains. If we continue it too long, we do hurt; for, if it be kept on when it produces continued pain, it induces a state of overaction, similar to that which it was intended to destroy. Whenever the surface becomes redder, and the pain less, it may be useful to employ some other application, such as laudanum, &c.

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

Lime water sometimes operates in the same way.

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

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

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

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

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

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

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

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

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

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

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

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

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

GENUS IV.

Of the Inflammatory Ulcer.

It sometimes happens, that the ulcerative action becomes converted into the inflammatory; the discharge diminishes, and sometimes ceases; the surface is red; and the edges and surrounding skin are elevated and inflamed. This, which has been called the phlogosis ulceris68, strictly speaking, does not belong to the division of ulcers, because the ulcerative action is destroyed; but, as it is preceded, and very quickly followed by this action, and as the solution of continuity, and other external appearances continue, this affection may be allowed to rank as a genus amongst ulcers, in conformity to common language.

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

GENUS V.

Of the Suppurating Ulcer.

This genus, like the last, accurately speaking, does not belong to the class of ulcers; but, as it is so intimately connected with it, both in its causes, and treatment, and appearances, it is of some practical utility to admit the arrangement.

When an abscess is opened before the ulcerative action is induced, we have an open suppurating sore; but this is not the sore which is meant to be described here.

The suppurating ulcer is, when simple, and independent of any specific action, most frequently only a high degree of the overacting ulcer; but, as its symptoms are somewhat different, and as it nearly resembles some specific sores, differing from these only in the absence of the peculiar action, resulting from the application of a poison, it may be proper to consider this as a separate genus.

When the ulcerative action is very imperfectly carried on, which often arises from overaction, we find, that the organic particles are thrown out, not in the form of granulations, but in a more inorganic state, and lie upon the surface, mixed with the discharge from the other set of vessels. This has the appearance of very thick tough pus, and the sore which yields it may properly be considered to be in a suppurating state. This ulcer is distinguished by the pain which attends it, by a redness which surrounds the margin, and a hardened base, whilst the cavity of the ulcer is filled up with a thick straw-coloured substance, somewhat like lymph, which adheres firmly to the surface. This is improperly called a slough.

This appearance and condition may be excited in a simple ulcer, without any apparent application of contagion; but it is still more frequently the consequence of some morbid matter acting on the part, and producing specific ulceration, which will be afterwards considered. I may only here observe, that it has, in some of these cases, been considered as a species of gangrene, as, for instance, in the cynanche maligna; but, whatever may take place in the advanced stages of this disease, there is at first no gangrene, but a suppurating ulcer, which throws out imperfect granulations, or rather a morbid purulent discharge (for the one runs naturally into the other), which forms what is called a slough.

The treatment of this ulcer consists first in procuring a separation of the tenacious covering, by such remedies as shall, at the same time that they do this, make the action more healthy.

A pretty strong solution of the argentum nitratum, or l’eau mercurielle, diluted with equal parts of distilled water, applied by means of a brush, frequently produce the desired effect.

The acetous infusion of Cayenne pepper, applied in the same way, is likewise useful.

Poultices made of decoction of camomile flowers, and equal parts of charcoal and barley meal, are sometimes of service in removing the matter, and rendering the action more truly ulcerative.

Opiates ought to be freely administered.

When this state of the sore is removed, the ulcer must be treated according to the condition of the ulcerative action. Most frequently it belongs first to the overacting genus, and must be treated accordingly, and then to the genus of indolent ulcers, in which case, pressure is to be employed as a termination to the cure.

When an overacting ulcer has, without the assistance of local applications, ceased to overact, it not unfrequently suppurates; that is to say, no granulations are formed, but the two sets of vessels throw out an inorganic matter, and the surface of the sore has a lymphatic appearance.

The best dressing for this state is dry lint, with a pledget spread with cerate laid over it.

Of the Effects of the Ulcerative Action on the Constitution.

The condition and qualities of an ulcer, do not, in every instance, depend upon causes which are entirely local, but frequently are connected with some general state, or mode of action, of the system. General weakness must, for example, influence the performance of any action in a particular part; and, therefore, an ulcer in those who are infirm, and exhausted, cannot readily perform the necessary healthy action, or proceed quickly toward a cure; nor is it easy, in these circumstances, by any local applications, to communicate the necessary action, and the correspondent power, which shall enable the part to heal. In the same way, there are some people so irritable, that an ulcer shall very readily assume the overacting state, which can only be removed by such remedies as act on the general system. Besides those which may be considered as simple conditions, there are many other actions, which are peculiar and unnatural, which influence the ulcer, or in which ulcers often appear as symptoms. These ulcers are specific, and must be afterwards considered.

As the state of the system has a considerable influence on the condition of an ulcer, so also has the state of the ulcerative action an effect on the constitution. A healthy ulcer, unless very extensive, has little effect on the system; but, unhealthy ulcers, or those which are very large, although the action may be sufficiently perfect, produce a greater or less degree of the general diseased formative action, or what is called hectic.

From the principles which have already been laid down, it may easily be understood how an unhealthy ulcer should induce hectic. When considering the doctrine of suppuration, the effects of this on the constitution, or the production of a general diseased formative action were attended to. It was also mentioned, when considering ulceration, that the ulcerative action had a tendency to produce similar effects; and this it does, with a certainty proportioned, cÆteris paribus, to the unhealthy condition of the action, or its approximation to the suppurative action; for the less perfect that the ulcerative action is, the more nearly does it resemble the suppurative one.

Healthy ulcers, if very extensive, produce likewise considerable effects on the constitution. This is chiefly perhaps owing to the purulent action, which makes a part of the ulcerative one; for this morbid local secretory action induces a general change, in the same way as other acute changes, of either the formative action itself, or any other intimately connected with it, such as the interstitial. But, besides this cause, the granulating action, although healthy, co-operates with the diseased interstitial action, or the purulent part of the ulcerative action; because, although the granulations, or organic particles, be healthy, yet they are formed in an unnatural situation, and with greater rapidity, and in greater numbers, in a given time, than naturally they ought to be; and, therefore, the action of the part requires greater power for its continuance than is possessed. There is consequently, then, weakness produced, which, by association, affects the system, and co-operates with the diseased formative action, increasing the general disease. The consequence of this state, likewise, is, that the ulcer comes, after some time, to be rendered unhealthy, owing to the deficiency of power to support the necessary action; in which case, the granulating action comes to be also diseased, and co-operates still more with the former morbid condition of the interstitial vessels, or the purulent action, which, although a part of a healthy ulcerative action, is yet itself a morbid secretion, and an unnatural action.

The effects of the ulcerative action on the constitution, are to be alleviated by good diet, free air, and the other remedies which have been pointed out when formerly considering hectic, to which I now refer. I shall only observe, that some of these remedies are employed occasionally with little judgment, and when they are not indicated. It is, for instance, a common practice with some, to prescribe the bark for the cure of every ulcer, whether the constitution be affected or not. But, from many trials, I am confident that it is of very little service, unless when a general disease, whether it be called weakness or hectic, exists.

When the proper remedies for the cure of hectic, conjoined with necessary local applications, fail, the diseased part must be removed; but, before doing so, it is, in every instance, proper to form a pea issue, in order still to keep up a secretory action, the good effects of which have been already noticed.

The restlessness, and febrile symptoms, which are sometimes produced by painful sores, are best relieved by anodynes.

Of the Cure of the Inflammatio Debilis, and the Treatment of Mortification.

The causes and nature of mortification having been already explained, I shall now consider the means of prevention, and the method of cure. The remedies necessary for procuring the resolution, or suppuration of the inflammatio valida, having been formerly enumerated, it will be unnecessary here to make any repetition, or to say more than that we are to prevent mortification by endeavouring to induce one or other of the other terminations, and that the remedies which do so are to be employed with a promptitude and assiduity proportioned to the greatness of the action compared to the powers of the part; and, therefore, that in the intestines, &c. we must pursue our course speedily, if we expect to prevent gangrene.

Mortification, however, is still more apt to succeed the inflammatio debilis, or inflammation of weakened parts; and, therefore, the treatment of this will now more naturally come to be considered, as forming a part of the prophylaxis of mortification, than in any other place.

The most frequent instance which we have of the inflammatio debilis, is the inflammation of parts which have been previously benumbed with cold; but it may also be produced by the action of any of the common exciting causes of inflammation, in weak and reduced habits, or by bruises in sound parts, &c.

When a part has been exposed to much cold, it may inflame, from two causes: First, the communication of action; secondly, the application of subsequent stimulants, more especially heat. Both of these tend to excite an action in the part, which is greater than its power would naturally perform, and, therefore, it becomes diseased, or inflammation is produced, and the little energy which did remain is soon destroyed. The operation of the first cause is prevented by lessening the action of the surrounding parts, by the application of moderate cold, whilst we avoid motion, and whatever may tend to act directly on the part, and co-operate with this cause. The operation of the second cause is prevented by keeping away every agent which will tend to excite action, or at least those which tend to do so suddenly. In the generality of cases, it is perhaps most proper at first to do nothing; because, whatever we apply, tends to excite a greater action than can be sustained; we ought, therefore, to delay any remedy until the part has begun to recover itself, and the action and corresponding power has begun naturally to increase; we may then interfere, by applying such remedies as increase the action, which are perhaps now more useful, by preserving the ground which is gained, than by increasing still farther the action. Of this kind is heat, which must, upon this principle, be applied with great caution, and must, in its degree, be nicely adjusted to the existing state of action. When a part, then, is benumbed with cold, we ought at first to apply a degree of heat, very little above that which the parts were formerly exposed to, which, in one sense, may be said to be doing nothing; for this step is intended merely to prevent farther injury. When this is continued for a short time, we may suppose that the part has begun to act a little more in a natural way, which is attended, as was formerly explained69, 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.

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 pharmacopoeia.

Internally, the bark must be exhibited in full doses, with such a quantity of wine as the feebleness of the pulse points out; but we must be prudent in this respect, because, if we give too much, we may increase the local disease. As long as it does not increase the pain, or quicken the pulse, it is to be considered as useful.

Opiates are extremely necessary in the inflammatio debilis, and, in general, require to be given freely.

Soups, and other articles of nourishing diet, are absolutely requisite, and ought to be given in small quantities at a time, but frequently repeated.

By these means, we may frequently resolve the inflammation completely; but, at other times, when we have gained a certain ground, the inflammation terminates in the suppurative action; or, in other words, when the parts have gained more strength, and the action has come more nearly to resemble the inflammatio valida, which has continued for some time, a similar termination takes place. This event cannot, perhaps, in these cases, be prevented, and, although it may occasionally protract the cure, yet it diminishes the danger, making mortification less to be dreaded. The best treatment, in these cases, perhaps, is to continue our usual applications, avoiding warm poultices until the action be fully formed; then moderate heat may accelerate the progress of the abscess toward the surface. The same internal medicines must be exhibited, the anodynes, however, being gradually diminished as the pain (which marks the necessity for their use) abates.

It too frequently, however, happens, that either our remedies fail, or the proper ones are not assiduously and judiciously employed, in which case mortification takes place. This requires the same treatment, in whatever way it is induced, only its progress is, from certain causes, more rapid70 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.

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 necessity71.

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 improper72. It is now indeed almost universally laid aside, owing, in a great measure, to the observations of the ingenious Mr. Pott.

Antiseptics, such as decoction of camomile flowers, &c. have been recommended as external applications; but, whatever effects they may have on the matter which is already dead, it is evident that they can be of no service in preserving the living parts from suffering death. All that can be expected from them is to check the putrefaction of the dead substance, which they have very little power to do; and, therefore, they can never come into competition with more valuable remedies, such as the camphorated spirit of wine, &c.

When, by the use of the remedies already mentioned, the progress of the gangrene is stopped, the ulcerative action is induced in the part immediately adjoining to the dead portion, and a red line of separation appears. By means of this ulcerative action, which takes place in every point where the mortification stops, the dead part is separated from the living, and comes away as soon as the bonds of dead muscular fibres, tendons, &c. which unite them, are destroyed by putrefaction. When this separation takes place, or when it is advanced so far as to permit us to accelerate it by dividing the loose tendons, &c. the exposed part must be dressed as an ulcer, or wrapped up in a poultice of the same temperature with the human body.

If, however, the disease have penetrated deep, and destroyed the limb so much as to render it impossible to cure it, or useless, if it were possible, then amputation must be performed; but this, whatever desire the patient may express, must not be practised until the mortification be fully stopped, and the ulcerative action induced; because, if performed sooner, the mortification seizes the stump, and the patient is quickly killed. The system is likewise in such a state as to be unable to sustain the action which is necessarily produced by the operation. It is even improper to cut too near the diseased portion; because the parts here, although the mortification be stopped, are so weakened, that they are less apt to unite. The vessels often break out soon after they are tied, and a new mortification is by no means an unlikely occurrence. Even when the amputation is performed pretty far up the limb, the corners of the stump frequently mortify, or become livid; but a few doses of bark and wine stop the progress of the disease.

Although it is a general rule that amputation is necessary whenever the member is so destroyed as to become useless, and although this must not be performed until the ulcerative action be induced, yet it must not invariably be performed whenever this action takes place, because sometimes at this period the patient is unable to sustain the general action which the operation would produce. We must, therefore, if the patient be much reduced by the extent, or long continuance of the disease, rather delay until, by good diet, wine, &c. we have procured an increase of strength; but, if we find that either the patient loses ground, or his weakness remains stationary under this treatment, we must then amputate; because, it is probable, that the continuance of the dead portion in contact with the living is tending to induce still the general action of descent73.

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 foetor, 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 expected74), 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.

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.