ULCER. 



order, before it has become general, are lying in a badly 

 ventilated part of the ward, or near fome fource of infeAion, 

 the furgeon can partly counterbalance the difadvantage of 

 not having a fre(h ward, by caufing the patients to be put 

 into a more airy part of the ward, and as far as pofllble 

 from the quarter in which they contrafted the difeafe. 

 Diet, internal medicines, and topical applications, form the 

 three eflential points in the treatment of hofpital gangrene, 

 after change of fituation, or purification of the air, when 

 that is imprafticable. 



When hofpital gangrene attacks a large wound or ulcer, 

 and the fever attending the complaint is confiderable, no 

 folid animal or vegetable food (hould be allowed. Where 

 more nouri(hment is required than can be obtained from 

 flops, tea, &c. thin rice-milk, weak gruels, &:c. will agree 

 better than broth or foup, which cannot be digelled without 

 confiderable diforder. In proportion as the heat and irri- 

 tation of the fyftem diminifh, the rice-milk and gruels may 

 be made fomewhat thicker, and when the patient can venture 

 to eat folid food, new-laid eggs, baked or boiled fruits, vege- 

 table difhes, fifh, and even what are called white meats, may 

 be given. The lefs meat, however, the patient eats, the lefs 

 liable will he generally be to a relapfe. 



With regard to internal medicines, while irritation 

 and febrile heat accompany hofpital gangrene, diluent acid 

 drinks are proper, fuch as nitrated whey fweetened with 

 fyrup of violets, lemonade, &c. Blood-letting is admifiible 

 in but few inftances, not merely becaufe the orifice made 

 by the lancet is apt to become gangrenous, but becaufe 

 the fever which accompanies hofpital gangrene is ufually 

 of the typhoid, or afthcnic charafter. Thomfon, p. 493. 



When the ftomach appears much opprcffed with bilious 

 complaints, an emetic ought to be adminiftercd. When 

 there is debility, good generous wine Ihould be allowed, 

 either by itfelf, or mixed with lemonade, according to cir- 

 cumftances, Bai-k, whofc antifeptic qualities have been fo 

 highly praifed, is in general more hurtful than uleful in this 

 diforder. Boyer, however, allows that it may be bene- 

 ficially given when the feverifli heat has abated, and the 

 debility is very great. He thinks alfo that the extradl is 

 the beft preparation. 



Acids are not liable to the fame objeftions as bark : 

 they are proper in all ftages of the difeafe, and their efficacy, 

 which has been proved in a vaft number of inftances, is the 

 more marked, the greater the dofes. The fulphuric acid is 

 that which is given with moft fuccefs ; but the acidulous 

 tartrite of potafla is alfo an excellent medicine. From two 

 drachms to half an ounce may be given every day, and the 

 beft plan is to make with it an acid drink, which ihould be 

 fweetened and ftraincd. 



In fevere cafes, attended with quick and feeble piilfe, de- 

 preflion, reftleflhefs, and anxiety, an opiate becomes necef- 

 fary. " So long as we wifh to excite a degree of moifture 

 on the fl<in (faj-s profeflbr Thomfon), Dover's powder, 

 or laudanum with antimonial wine, form in general the beft 

 opiates." This gentleman, however, is not an advocate 

 for the employment of opium in the early ftage of hof- 

 pital gangrene, while the heat and other febrile fymptoms 

 are at their height. ( See Leftures on Inflammation, p. 494, 

 495.) For thefe cafes, camphor was highly praifed by 

 Pouteau. 



With refpeft to the local treatment, it is at leaft as im- 

 portant as the conftitutional. Indeed, the French furgeons 

 conceive that it is much more fo. " I was told by feveral 

 of the French furgeons," fays a late vifitor to Paris, " that 

 they did not rely at all on internal means for flopping the 

 prcgrcfs of hofpital gangrene, and that their experience had 



proved them to be infufiicjent, if not wholly iuefEcac!ou$> 

 Dupuytren, in reply to the account I gave him of the prac- 

 tice and opinions of Englilh furgeons on this fubjeft, aifured 

 me, that he had no confidence but in local apphcations ; and 

 that internal remedies alone, as far as he had found, did almoft 

 nothing." The fame remark has been made in a very recent 

 publication on hofpital gangrene (Delpech Mem. fur la 

 Complication des Plaies, &c. 1815.), although it feemstobe 

 rather at variance with its being a conftitutional and conta- 

 gious difeafe, which the author has admitted. See Sketches 

 of the Medical Schools of Paris, by J. Crofs, p. 83. 



Perhaps there is nota fingle antifeptic application which has 

 not been tried as a dreffmg for wounds or ulcers affefted 

 with hofpital gangrene. All watery applications, and com- 

 mon poultices and fomentations, are generally condemned 

 as inefficacious, and even hurtful, in the treatment of this 

 diforder. 



M. DufFaffois was convinced by the obfervation of nu- 

 merous cafes, that the beft apphcation is powder of bark. 

 He recommends the wound to be covered with feveral layers 

 of this powder, which are then to be moiftened with turpen- 

 tine. When this compofition dries, it forms a fragile fort 

 of coat, at the fides of which, and through which, the dif- 

 charge efcapes. After twenty-four hours, the firft coat tr 

 to be removed, and a frefti one applied. In general, four or 

 five fuch drefTings are fufScient in limple cales, wl\ere the 

 diforder is confmed to the ficin and cellular fubftance. 

 Healthy inflammation then occurs, the floughs come away, 

 and the wound puts on a healing appearance. Duflaffois, in 

 bad cafes, fometimes added one-fifth of powdered muriate of 

 ammonia to the powder of bark. In mild inftances, as we 

 learn from Mr. Crofs, the modern furgeons in France alfo 

 employ with fuccefs vegetable and diluted mineral acids. 

 P. 84. 



But when, by tlie employment of thefe means, and of the 

 other remedies which have been enumerated, the progrefs of 

 the diforder caniiOt be checked, and all the furrounding foft 

 parts are ihreat-jncd with deftrutlion, Pouteau, Duflaffois, 

 and other French furgeons, even thofe of the prefent day, 

 have immediate rccourfe to the aftual cautery, and repeat the 

 application of it, until the whole furface of the ulcer is con- 

 verted into a firm hard efchar. Even the edges of the 

 folution of continuity Ihould not be fpared, — " ils doivent 

 etre torrefies ct r6tis pour ainfi dire." (Boyer, Traite des 

 Maladies Chir. t. i. p. 332.) The efchar is then to be co- 

 vered with a thick ftratum of bark, moiftened with turpen- 

 tine. This application is to be removed in twenty-four, 

 thirty-fix, or forty-eight hours, and the furgeon is then to 

 judge from the appearance of the flefh, and the quality of 

 the difcharge, whether a further repetition of the cautery 

 will be neceffary. 



Although we thus find from the accounts of Boyer, Mr. 

 Crofs, and others, that the modern French furgeons ftill re- 

 gard the aftual cautery as the only efTeftual means for 

 flopping the progrefs of bad cafes of hofpital gangrene, 

 their opinion has fortunately not been adopted in this country. 

 Nothing can be a greater proof of fuch fevere praftice being 

 at .aU events unnecetfary, than the faft that many bad cafes 

 of hofpital gangrene have done well without it, and even its 

 greateft advocates cannot prefume to affert that it will always 

 effeft a cure. 



Inftead of the aftual cautery, the apphcation of boiling 

 oil has been propofed ; but the advocates for red-hot irons 

 maintain, that the heated oil does not extend its aftion to 

 a fufficient depth. 



A phlegmonous fivelling at the circumference of the 

 wound, or ulcer, evinces, that the ravages of the difeafe are 



ftopped, 



