When the mortification has stopped, a defined boundary separates the dead and living parts; the lymphatics remove the connecting matter, so as to form a groove, in which suppuration commences ; and this groove extends deeper and deeper, until complete separation is effected. Our treatment must be directed to the object of stopping the disorder; in which view attention to the constitutional dis. turbance, that is usually very great, is of primary importance. The state of the digestive organs will demand particular attention. The great pain frequently re quires opium. Cold washes while the inflammation continues high ; and after. wards a poultice of bread or linseed, alone, or in combination with very finely powdered charcoal, are the best topical means. Amputation of a limb can never be allowed, null' the line of separation between the dead and living parts clearly formed. When the inflammation is abated, and the separation is going on, (which should in general be left en tirely to nature,) the constitution should be strengthened by every means both of food and diet. Hence bark, with wine and aromatic confection ; fermented liquors, and • nourishing diet, become proper. Bark, however, is by no means so universally beneficial in mortification as many • surgeons suppose : if sympa thetic inflammatory fever be present, or derangement of the chylopoietic organs, it would certainly be hurtful ; but, where debility shews itself, this remedy must be instantly employed. Opium is often very serviceable ; and it has been represented by Mr. Pott as almost a specific in the mortification of the toes and feet of old persons, where it must be used in a very free way. The same remedy will be of service in other cases, where the disorder is preceded and accompanied with great pain, but not inflammation.
Erysipelas is a species of superficial in flammation, in which the red colour is tinged more or less with yellow, parti cularly towards the termination ; it spreads rapidly and widely ; there is swelling, without much elevation, hard ness, or circumscription. The skin is glossy, and its colour disappears on pres sure. The pain is of a burning or itch ing kind. It often changes its seat; and is attended, when it recovers, with des quamation of the cuticle. Sometimes vesicles are formed. It seldom suppu rates; but when it does, the abscesses are very extensive, as adhesions seldom take place, to limit the expansion of the matter. Mortification ensues in some in. stances.
The constitutional affection varies con siderably, according to the degree of local disturbance. Langour, head-ache, loss of appetite, nausea, vomiting, op pression of the stomach, and foul taste in the mouth, precede. It is most dan gerous in the face, and attended with the greatest disturbance, often amounting to delirium.
Disorders of the chylopoietic viscera, and suppressed perspiration,are the most prominent causes of the complaint. Mild purgatives, diaphorencs, and the anti phlogistic regimen, are sufficient in the slighter cases. In more severe attacks, calomel, combined with other purges, and antimonials, is proper. Emetics, where the stomach is much distressed. Bark may be required after the disorder subsides. Cold washes, or poultices, to the part, as they seem to agree : the for mer are preferable, on the principle of checking the inflammation.
Carbuncle is a very violent unhealthy kind of inflammation, attended with a painful deep discoloration of the skin, a very remarkable thickening and indura tion of that part, and gangrenous suppu ration under it, occurring usually at the back part of the trunk, and often consti tuting a symptom of the plague and other malignant fevers. Its size varies consi derably. Openings form in the swelling, and give issue to a very offensive dis charge ; and in the end extensive morti fication ensues. The fever, which is at
first inflammatory, soon becomes typhoid; and strong marks of cbylopoietic derange ment are generally attendant.
The swelling must be completely laid open by a free incision through the braw ny skin, so as to discharge all the matter and sloughs. Purgatives and emetics are proper for the disturbed digestive organs; and the debility which remains after the disorder has subsided demands strength ening medicines and food. Opium, when the pain is excessive.
Boils are similar to carbuncles, except that they are smaller, and require the same treatment; the state of the chy lopoietic organs must be particularly re garded.
edema is an unusual accumulation of water in the cellular substance, occasion ing a general swelling of the part, with out discoloration, that pits on pressure, is uneasy rather than painful, and in creases in a depending position. It arises from constitutional or local weak ness. In the latter case, which alone be longs to surgery, let the cause be remov ed; put the limb in a horizontal posture; employ frictions with flannel, and cam phorated, or other slightly stimulating applications, and then apply a moderate ly tight roller.
Burns are attended with violent in flammation of the part, severe pain, and fever. The cuticle is raised into clear yellow blisters. The part may be de stroyed at once, and converted into a dead black substance, or it may slough from the subsequent inflammation. If vesications do not form, suppuration will probably not take place. Where the in jury is very extensive, the breathing is much affected.
As burns are violent local inflamma tions, the antiplalogistic treatment, both locally and generally, was the usual sur gical practice, until Dr. Kentish, who then practised surgery at Newcastle, in troduced the opposite, but, as subsequent experience has proved, much more suc cessful plan of applying bot oil of tur pentine, or alcohol, and then covering the part with a liniment composed of ung. resin. flay. and ol. tereb. on the principle of maintaining the action of the part by an adequate stimulus, which is to be gradually diminished. The first dressing remains for twenty-four hours; and in the second, warm proof-spirit, or laudanum, may be used before the plas ter is applied ; which alone suffices for the third. When suppuration com mences, powdered chalk, and a plaster of cerat. lap. calam. Opium and good diet are to be allowed at the commence ment of the treatment, with the topical stimulus.
Elects of cold When a limb has been frozen, heat must be communicated to it very gradually. The sudden application of considerable warmth will inevitably cause mortification. Rub the part with snow, as persons in northern countries do their ears or noses when thus affect ed, or with cold water, until motion and sensibility return. Then camphorated spirit of wine may be used, and, ultimate ly, a moderate approach to the fire may be allowed ; or else the patient may be put in a warm bed, and warm flannels may be applied locally ; general perspi ration being at the same time promoted. The same principles must be kept in view when the whole body is affected. Volatiles and stemutatories may be used when animation has returned; and warm wine or spirits should be introduced into the stomach as speedily as possible.
Chilblains are caused by exposure of parts to the vicissitudes of heat anditold, particularly in young persons, females, and such as are brought up tenderly. Before they are ulcerated, ice, cold wa ter or snow may be applied two or three times a day; and the parts should be kept dry, and in an uniform temperature. In some cases, topical stimulants seem more beneficial, as spit. yin. camph. or tinct. myrrhat rubbed in; also vinegar and alum lotion. Sp. yin. camph. and tinct. cantharid. in equal parts, have been very useful.