Dr. Boggie admits that “in that form of gangrene named phagedena, a very great destruction of parts may sometimes take place without the constitution being much affected by it. Now, if blood-letting be used in such a case, or even in the advanced stage of the true inflammatory gangrene, when disorganization has taken place, and the system is sinking under the consequent debility, the vital powers being nearly exhausted, the result must be obvious; but when it is used with caution, and in cases where it is really applicable, it will be found to be a most valuable remedy.” In all cases, Dr. Boggie, like every one else, had recourse to emetics, purgatives, and such other general treatment as the febrile symptoms appeared to indicate. As local applications, he recommends cold water, alone or mixed with a small portion of acetic acid, constantly applied and frequently renewed. Poultices and warm applications he objects to; and after the sloughs separate, he approves of dry lint and weak solutions of sulphate of zinc. Should the sloughs adhere after the inflammation has abated, warm, stimulating ointments, and sometimes weak solutions of the nitrate of silver or of the mineral and vegetable acids, may be had recourse to.
169. To Mr. Blackadder must be attributed the introduction of the use of Fowler’s solution of arsenic as an escharotic, in November, 1813, while he was at Passages; it answered remarkably well in arresting the progress of the disease, and was afterward found to be equally efficient in the hospitals at Antwerp. The only objection to its use that I am aware of is, that it caused in some few cases slight symptoms of its poisonous effect having taken place on the bowels, apparently from absorption,—an inconvenience which might become a serious evil, and which caused a preference to be given to the mineral acids, which act equally well without incurring a similar risk of evil. Mr. Blackadder, stationed on the same coast, within about forty miles of Dr. Boggie at Bilbao, took a diametrically opposite view of this complaint to the doctor; and believing the disease to be purely local in the first instance, considered venesection as almost always unnecessary, although he admitted that cases may occur in which the abstraction “of a small quantity of blood would be likely to be attended with more good than harm; but certainly,” he adds, “blood-letting is an operation which ought to be avoided as much as possible in gangrenous phagedena, particularly when the previous injury has been extensive, such as that of a penetrating gunshot wound.”
Dr. Walker, who served at Bilbao at the same time, concludes an able report in the following terms:—
“Lately, however, the disease put on a milder form, and the sloughing did not proceed with that rapidity that it did at first, nor was the fever so violent. And more lately still, since the setting in of the cold weather, the type of the fever seems to have changed entirely, and to have put on the inflammatory type, so as to require strong evacuants, and even bleeding, which has been used with the greatest success by Staff-Surgeon Boggie, who has for a considerable time had the more immediate care of the patients of this description at the Cordeleria Hospital.”
170. “When this disease does not proceed rapidly, and is confined to the ulcerative form,” Delpech says, “it may be removed by stimulant applications, such as vinegar, the vegetable and mineral acids, the Egyptian ointment, etc.” Of these he prefers vinegar applied on lint, after having rubbed or scraped off any false or pulpy membrane which appears to conceal the surface of the ulcer. “Some good effect,” he adds, “has been observed from the careful application of powdered charcoal to the whole surface of the sore, which,” he says, “ought not to be in the gangrenous, or pulpy, or putrid state, but merely ulcerative or phagedenic; and not even then, when this peculiar ulceration assumes a deeply hollowed-out form, rapidly filled with an abundant and tenacious discharge.” Of constitutional treatment he evidently thinks little; and, while he admits the propriety and necessity of treating every accompanying state of fever, whether it be inflammatory, catarrhal, bilious, remittent, etc., by its appropriate means, he does not seem to think they have much influence on the local disease, although he firmly believes that the suppression of the local disease materially assists in arresting, in a great measure, such constitutional symptoms as may be dependent on it, unless influenced by some peculiarity of constitution. His principal local remedy was the hot iron or actual cautery applied to every part.
He says (page 86) some surgeons of the Anglo-Portuguese army of Lord Wellington had assured him that the mineral acids, the hydrochloric, nitric, and sulphuric, had been frequently employed in the British hospitals in Spain with success; and he particularly mentions M. Guthrie, Inspecteur au Service de Santé, as the person from whom he especially received his information; thus establishing the fact that the use of the mineral acids in a dilute and concentrated state was known to, and had been essentially introduced into practice by, the surgeons of the British army during the war in Spain—a fact which admits of no dispute as to the origin of its use.
171. In India, Mr. Taylor, late surgeon 29th Regiment, now a deputy inspector-general in the medical department in the Crimea, reports:—
“Hospital gangrene appeared among the wounded of the 29th Regiment a little later than in the hospitals of other corps. The disease declared itself, on the 18th of January, in a stump case; and between that date and the 26th of the same month fifteen cases had come under treatment. At first I could tell, by the peculiar dark, florid countenance of the patient, that his wound had taken on the gangrenous affection; yet I cannot say that there was, in these cases, any marked inflammatory fever. Subsequently, in the prevalence of the disease, this dark-red color of the face was neither well marked nor by any means so constant. In many cases the disease seemed purely local; but in the great majority there was certainly much feverish constitutional disturbance accompanying the local affection, and often preceding it. My experience of the disease, as it occurred among the wounded at Ferozepore, does not enable me to determine, satisfactorily to myself, whether it be essentially a local or a constitutional affection. I am inclined to place it in the former category; and there is no doubt whatever in my mind that the essential means of treatment are local.
“In the treatment of this disease, I proceeded regularly on one plan, and found that so efficacious that I was not inclined to try any other. The plan adopted was, the application of the strong nitric acid, so as completely to cut off the diseased from the sound part, or part so far sound as only to be affected with inflammation. The acid, however, required to be rubbed in with the blunt end of the probe, so that it not only destroyed the cuticle, but killed the cutis vera, and probably the cellular membrane underneath. The narrow yellow ring of dead skin thus formed separated like a piece of leather, generally carrying with it the whole slough, and leaving a clean, healthy surface, as well as edges to the wound. I never attempted to apply the acid to the surface underneath the slough, neither is such an application necessary; the vital seat of the disease is in its circumference, however large the area. I must admit that the disease sometimes crossed the acid boundary, and a second, and even a third application of the remedy was required; but this was rare. Neither was constitutional treatment neglected, but this varied according to the state of the patient; emetics, purgatives, saline medicines, and low diet being sometimes required; while in other instances ether, ammonia, laudanum, and generous diet were administered.
“When speaking of the symptoms of this disease, I should have mentioned that a burning, gnawing sensation was sometimes loudly complained of. The application of the acid soon removed that pain, and the acid itself did not often seem to produce much suffering. In one instance, deemed a favorable one, I tried venesection, and I fear did mischief. Calomel and antimonials were useful. I did not try the arsenical solution. The change of air, which the march of the wounded, on their return to Kussowlee, occasioned, certainly had a very beneficial effect on all the gangrenous and sloughing sores.