Dissertations on Inflammation, Vol. 2

by John Burns

These remedies may give a temporary check to the disease; but, unless nourishment be conjoined, in every possible form, they will not of themselves be able to effect a cure, if the disease be tedious. Soups, jellies, milk, sago, &c. must be assiduously given in small quantities, and even thrown up as clysters, if the stomach cannot bear them.

Vegetable acids, fixed air, wort, &c. have been recommended in this disease, probably upon the supposition of the existence of a putrescent matter, or from their utility in scurvy. Wort, however, and fixed air, do not appear to be of very great benefit in this disease, at least they are by no means to be put in competition with other remedies of more approved efficacy, or allowed to interfere with their exhibition. The acid of lemons seems to be more generally useful than the carbonic acid; and, perhaps, the nitrous acid would be equally useful with the citric acid. These acids do not operate by counteracting putrefaction, but by counteracting the action of descent, inducing a more healthy action, and tending to excite ulceration, which is the mean employed for separating the dead part, and producing restoration. For this purpose, however, the acids must be given freely, otherwise no good is done.

The local treatment is to be conducted on the same principle as in the cure of the inflammatio debilis. Pledgets, dipped in the oil of turpentine, tincture of myrrh, or rather in camphorated spirit of wine, which is one of the best applications which can be used, ought to be made use of.

These remedies can do little service when applied to the dead portion; but, as the whole part does not die at once, there are always some portions which are still in the inflamed state, and on which they act. They likewise prevent the progress of the disease, by operating on the skin which is contiguous to the gangrene. Every mortification, in general, attacks the skin first; or, in other words, the inflammatio debilis spreads faster along the skin than along the deeper parts; but, when once the skin is inflamed, and mortifies, the disease extends to a greater or less depth below the surface. Whatever, then, operates on the surface, and prevents the progress of the inflammation, or cures the part which is already inflamed, will tend to check the extension of the disease, especially if the proper internal remedies be made use of with a view to prevent the extension of the action of descent.

Formerly, in order to allow these remedies to come in contact with the living parts, it was customary to make incisions through the dead portion, and not unfrequently through part of the living substance. But, as these cannot prevent the extension of the disease over a greater surface, and, as the irritation which is given, and the exposure of parts which have not yet assumed the ulcerative action, tend to increase the inflammatio debilis, the practice must be considered as improper[72]. 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 descent[73].