Dissertations on Inflammation, Vol. 2

by John Burns

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 spot[76]; 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 ulcerated[77]. 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.