On the Phagedenic, and some other Species of Specific Inflammation.

When any peculiar modification of the inflammatory action takes place, specific inflammation is said to be produced; that is to say, the action possesses some peculiar or specific qualities, independent of the simple condition of inflammation; and these are generally productive of evident and visible effects, which are characteristic of their presence; but, until these effects, which are chiefly observable in the appearance of the consequent ulceration, appear, it is frequently impossible, from the symptoms of the inflammation alone, to say that it is specific; because the evident effects, or symptoms of the inflammatory action, such as heat, pain, redness, &c. admit of few specific alterations, varying only in degree, and this variation taking place often without any specific affection of the action75.

The effects of the ulcerative action admit of greater variations than those of the inflammatory, and, therefore, more readily show the presence of specific action. The healthy ulcerative action exhibits certain appearances which have been already described, and which are easily known. The simple deviations which have been treated of, in considering the different genera of ulcers, are also discoverable by the effects, or peculiar symptoms. The specific deviations dependent upon the presence of previous specific inflammation, or the application of a morbid agent, after simple ulceration has been induced, may also, in many cases, be detected and ascertained, by the variations which take place in the aspect of the sore, the appearance of the granulations, discharge, &c.; but these variations and appearances consist so much in peculiar hues and qualities of the granulations, which we have no words to convey an idea of, that it is impossible to give an accurate description of a specific sore, but must see it in order to obtain an idea of it. We may indeed say, that a sore is ragged, has a fiery look, is surrounded with an erysipelatous margin, and discharges a thin foetid matter, but still we shall not convey the idea of the specific appearance of the ulcer.

It is this specific appearance alone which characterises a specific ulcer; and this, in each peculiar ulcer, is different; and a knowledge of it can only be obtained by an attentive examination of many sores. On this account, it is extremely difficult, in many instances, to distinguish a specific ulcer, because the discrimination depends altogether upon the recollection of the practitioner, and the improvement which he has made of his former observations. It is indeed, it may be thought, an easy matter to distinguish a simple ulcer by negative characters, or the want of the peculiar aspect; but, as this aspect is very arbitrary, and as the appearance of simple ulcers is, as has been already described, very various, it is difficult to say, without much judgment, whether the sore be simple or specific; for the appearance of the one and of the other run imperceptibly into each other. Even if it be ascertained to be specific, it is difficult often to distinguish betwixt particular specific diseases, in so much, that many are forced to take mercury for the cure of syphilis, who never had that disease.

Besides the appearance of the sores, specific action likewise produces a perceptible effect upon the scab which covers them, or the cicatrix which is formed. Thus, scrophula is marked by a particular appearance of the cicatrix, or of the scab. The venereal ulcer has likewise a particular scab, and many cutaneous ulcers are best distinguished by the scab. Other actions produce no considerable ulceration, but only successive desquamation of the cuticle.

We may also sometimes discover specific action by the sensation of which the action is productive. Thus, for instance, cancer produces a burning kind of pain, which never attends simple ulceration.

Specific ulceration is also always surrounded with more or less simple inflammation, or erysipelas, of the surrounding skin. In some cases the margin is hard, in others ragged, &c.

It were much to be wished, that some more certain, and less arbitrary criteria, than those which we possess of the presence of specific action could be discovered; but, as yet, we know of no other which can be applied universally. Some kinds, indeed, are so well marked, and so peculiarly distinguished from simple sores, that they can be tolerably well described, and easily discovered to be specific; but, there are others which it is more difficult to ascertain, owing to the difficulty of fixing the character of each individual action.

The number of specific inflammations is very great, and the causes which produce them are often obscure. In the preliminary dissertation it was mentioned, that, whenever any action existed strongly in any one part, it tended to induce an inflammatory state. There are, therefore, no general, or febrile diseases, which may not be attended with peculiar inflammations. That typhus fever is attended with local inflammatory action is pretty certain; but the presence of specific inflammation is still more evidently seen in the different exanthematous diseases. The diseases called cutaneous, afford us also numerous instances of specific inflammation.

From the difficulty of discriminating betwixt diseases, which, although essentially different from each other, yet possess a very great similarity, we find, that the number of specific inflammations is confined much within the true limits; for we find many confounded under the name of herpetic, &c. which are radically different from each other.

Phagedena has been used by medical writers in a very extensive sense, and has been made to comprehend diseases, which, strictly speaking, cannot be considered phagedenic.

The phagedena is a suppurating sore, dependent upon the application of a peculiar contagion. No granulations are formed, but both sets of vessels yield a thin fluid. The surface of the sore has a jagged appearance, dependent upon the irregularity of the absorption, and not upon the deposition of organic particles, or granulations. The colour of the surface is dark, but clear, or fiery. The surrounding integuments are erysipelatous. The discharge is thin and serous, and the pain considerable. This is divisible into two varieties: First, the true phagedenic, which does not go deeper than the skin, but spreads rapidly along the surface. This kind frequently stops in its progress suddenly, and skins over as fast as it spread. Second, the noma, or penetrating phagedena, which extends deeply, penetrating sometimes perpendicularly down through the cellular substance to the muscular fascia; at other times, proceeding more irregularly, penetrating deeper at one part than another, and having its margins ending less abruptly in the neighbouring skin. This never cicatrizes rapidly; but, sometimes, when the sore assumes a healing appearance, it suddenly becomes again diseased, and a considerable portion sloughs off. The alternation of proceeding a certain length in the cure, and relapsing, is frequently repeated, and often renders the disease very tedious.

The best application for the common phagedena is an ointment consisting of an ounce of ung. resinos. and a drachm of red precipitate.

The application of caustic to the surface also frequently stops the progress of the disease.

The hepatized ammonia, much diluted, is also very useful as a lotion.

The penetrating phagedena is more difficult to cure; for, even after the diseased action is removed, the ulcer remains in an irritable, or overacting date. The application which I have found most useful is powdered opium, mixed with simple ointment, in the proportion of two drachms of the former to an ounce of the latter. After the phagedenic action ceases, the sore must be treated according to the genus of simple ulcer to which it belongs.

When the sores seem to pursue their ravages obstinately, the most effectual mean of stopping their progress (until we discover a specific remedy, or one which can change the nature of the action), is to apply the caustic to every part, and so freely, as to produce a pretty thick slough. Whenever this appears to separate, precipitate must be applied, in order, if possible, to prevent the recurrence of the diseased action.

When any considerable vessel is eroded, by the continuance of this disease, it must be tied beyond the diseased part; but we must be careful that no matter from the sore gets upon the wound, otherwise it will become diseased also. I have a preparation, in which a part of the femoral artery was opened at the groin by this kind of sore, which succeeded a venereal bubo. No operation, I understand, was attempted, but compression alone used. The man died in a short time. Whether tying the iliac artery, by cutting through Poupart’s ligament, would have saved him, is difficult to say.

The true phagedena seems always to confine its action to a particular spot76; but many of these diseases, which have been described under the same name, appear to be capable of inducing a general action, similar to the venereal disease, affecting different parts of the body in succession. A case of this kind is related by Mr. Adams, in his Observations on Morbid Poisons: A gentleman who had a small pustule on the prepuce, squeezed it so as to make it burst, and soon afterwards had connection with a woman whom he had long known. The sore remaining without healing, he applied a solution of caustic, and had recourse to mercurial frictions. But, notwithstanding these, the ulcer spread, and soon reached the scrotum. The mercury was now laid aside, and bark, with a good diet, were substituted, after which the ulcer put on a healing appearance; but, before cicatrization took place, a feverish fit supervened, with violent pain in the part. In the course of a short time, however, the unfavourable symptoms disappeared, and a healthy condition was again apparently induced. These paroxysms of fever, and subsequent amendment, alternated with each other for a considerable time, and each relapse was preceded by a livid appearance round the sore. These appearances at last went off, and the sore assumed more the aspect of the true phagedena. The cicatrizing process now began at the upper part, and proceeded rapidly until almost the whole sore was covered. But, nearly about this time, copper coloured spots appeared on the hands, and the inside of the right thigh; and, in a day or two afterwards, an ulcer appeared in the throat, with “bumps” on the head. Shortly afterwards a node appeared on the tibia, and the patient became bandy. The blotches speedily began to ulcerate, and another appeared on the sternum. Mercury was now given freely, and at first with apparent success, for the ulcers looked better, and no new affection appeared; but, whenever the mercurial action was beginning to be fully induced, the granulating appearance of the surface was destroyed, and it became of a dusky colour, discharging “bloody sanies.” The bones remained stationary. The medicine was now discontinued, and the patient went to the country; but, on his return, in about a fortnight, “his throat was again ulcerated77. Such of the old external ulcers as had not healed, threw up a kind of fungus granulations.” The sore on the penis, which never had been completely well, had spread to the size of a shilling, but had no phagedenic, or specific appearance. Mercury was afterwards tried, and some bones exfoliated from the nose. The ulcer healed; but, as soon as he recovered from the effects of the mercury, new blotches and ulcerations, with a new enlargement of the tibia, took place. “He is now under his fifth mercurial course.”

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

There are several other ulcers, which appear upon the penis after coition, which probably depend upon the application of a peculiar contagion. These78 are sometimes superficial and phagedenic; they spread fast, and heal rapidly, frequently in the course of a night after precipitate has been applied. At other times they are deeper, and more like a little cup; the surface is smooth and glossy, without any appearance of granulations; the discharge is thin, and the base and margin quite soft. The best remedy is the caustic, with the subsequent application, precipitate, or ung. hyd. nit. dilut. When buboes form, I have always found them heal without the use of mercury. If, however, the bubo be the first symptom which appears, as is sometimes the case, (for the morbid agent is occasionally absorbed before it excites action in the part to which it is applied), then it is generally much more difficult to heal than when it is preceded by a local action, and induced by the absorption of matter generated there.

If these local, or primary symptoms, be not speedily removed, a general disease is induced, as we see in the case already mentioned, and as is proved by numberless other instances. These general affections are marked by ulcerations of different parts; and the ulcers have a different appearance, according to the nature of the morbid agent. In some cases they are better and worse at intervals. Mercury has, in almost all these cases, been used; but, although some are ameliorated by it, yet others resist its action. At first, indeed, they generally appear to heal; for the mercurial action, when forming, interrupts the progress of the former diseased action; but, whenever the mercurial action is fully induced, we sometimes find that the appearances change, and the progress generally becomes quicker than formerly79.

There is a disease which is not unfrequently confounded with syphilis, but which is distinct from it; I mean small ulcers about the mouths of children, which are more like aphthÆ than any thing else; but, soon after their appearance, small blotches appear in the body, which become first raised into a little flat vesicle, and then ulcerate superficially. These ulcers have a watery appearance, not much unlike tetters; but the appearance of the vesication, and dark colour of the preceding blotches, prevent any confusion. Nurses who suckle these children have generally small calyciform ulcers on the nipples, of a pale colour, and discharging a thin watery matter. I have had no opportunity of ascertaining what constitutional symptoms would be produced by the continuance of the disease in the nurse, as I have generally found that the application of diluted citrine ointment to the nipple produced a cure, without any internal medicine. The constitutional symptoms in the children were cured by the same local applications, with small doses of calomel internally80.

I have likewise observed ulcers on the lips, throat, and mouth, which at first had a very doubtful appearance; but they evidently are distinct from syphilis, and belong to the suppurating sores. When superficial, the buff-coloured matter, or inorganised substance which covers them, has a fibrous, or thready appearance, the margins are slightly tumid, and of a florid, or kind of pink colour. The application of caustic, or burnt alum, is often sufficient of itself to cure these; but small doses of mercury sometimes accelerate the cure. At other times these sores penetrate deeper, and affect the bones. The surface, which is deep, is covered with a thick yellow slough, like an overacting ulcer. The margins are tumid, ragged, and of a light, or pink colour. Sometimes the disease spreads along the gum, which becomes soft, ulcerated, and separates from the teeth, which very frequently become black, and, when the sockets are affected, drop out. I have not had an opportunity of observing these sores go the length of inducing constitutional symptoms. It is not easy to ascertain the cause of these sores; sometimes they succeed the use of mercury; but, at other times, it is impossible to blame any evident agent. The transplanting of teeth sometimes has been the mean of inducing sores similar to these; and, in these cases, the disease has generally passed for syphilis81. But although the venereal disease may have been inoculated in this manner, it is certain, from the appearance of the ulcers, from their rapid progress, and from the sudden effect produced by a very small quantity of mercury, that the disease, which is commonly induced by transplanting teeth, is not syphilitic.

Sibbens is another disease which has been very frequently confounded with syphilis, and is by many considered to be only a variety of that disease; but they evidently are different, as appears from the mode of infection, and the properties of the contagion82, the appearance of the ulcers, their progress, and certain circumstances in their cure, particularly their requiring less mercury than venereal ulcers in the same state, and from their yielding readily to preparations of mercury, which do not accomplish a cure of syphilis.

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

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

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

Herpes83 is a disease which is very frequent, and often prevents large ulcers from healing, as these come to assume the action of herpetic ulcers, although, from their magnitude and depth, they do not put on the same appearance as when the disease is confined to the skin. The large ulcers are of a dark sloughy appearance, discharge thin matter, are painful, and are surrounded with herpetic ulcers, and scabs in the skin. This is a very frequent disease on the legs, and is very tedious. Bathing with warm sulphureous water is often of service, at the same time that we dress the parts in the intervals with camphorated ointment. Citrine ointment is also very useful; but the following liquor is one of the best, and most effectual applications:

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

This ought to be applied with cloths to the parts.

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

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

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

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

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