There is an ulcer which precisely resembles this phagedenic sore in appearance, for they ought to be considered one, being purely phagedenic, but which only attacks the face, and from its supposed contagious nature is named Nali me Tangere; and is classed by authors under the herpetic ulcer. It generally begins at the alx of the nose, but not unfrequently in the upper and even the lower lip, also in the forehead or angle of the eye, hence no part of the face is exempt from its first attack, and spreads upwards, downwards, and central, until it ultimately removes the whole countenance, producing hectic fever, and repeated hemorrhagies, when death closes the scene. its characters are identically the same as the phagedenie ulcer last described, and need not therefore be repeated. The ulceration however is preceded by a yellow pustular or scabby eruption, surrounded by a violet-coloured circumscribed inflammation. These moist yellow spots either fall off, or are picked off by the patient, mid expose this ulceration, discharging at that time a thin serous acrid matter. When the in flammation is moderate, there is commonly little pain, but when severe, there is an acute burning pain, and more or less concomitant fever. It is a most inveterate ulceration, and unless treated in its earlier stages, often foils the labours of the surgeon. The treatment should be the same as that recommended for the simple phagedenic ulcer; but if it does not succeed in curing it, the chloride of lime very much diluted may be tried. The fol lowing ointment sometimes produces beneficial effects, 3ss of camphor, 3iij of the white preci pitate of mercury, hiss of the prepared carbonate of lime, and ij of lard finely levigated. If after all, the ulceration continues inveterate, the whole base should be excised if practicable, and if not, destroyed or eaten away with the crude nitrate of copper. Some use equal parts of alum and chalk to the edges in order to destroy the diseased structure. A number of authors consider this disease con stitutional, and recommend arsenic, antimonials, mercury, purgatives, and sudorifics internally, with vegetable diet and warm baths. There does not appear however the least ground for considering it constitutional, as it begins locally and continues so nearly to the conclusion of the horrid scene. What seems to have deceived us on this subject is, that all ulcers heal from the powers of the con stitution, consequently when these are too vigorous or too languid, the healing process does not take place. The constitution, as well as the ulcer, re quires to be sound or healthy.
Tinea capitis is also classed under this ulcer, and is a variety of the herpetic or creeping ulcer ation. Tinea capitis, porrigo, or scald head, con sists of six species, according to Bateman, but we shall limit ourselves to two, the porrigo fur furans, and the porrigo scutulata. Porrigo fur furans, or tinea capitis, begins with an eruption of small achores, the excoriation is slight, and the discharge concretes and falls off in innumerable thin laminated scabs. Fresh pustules arise and follow the same course, until the greater part of the scalp of the head is involved. The hair partly falls off, and there is intolerable itching and sore ness. This affection commonly begins in early life from inattention to cleanliness, and a peculiar prejudice of the parent against washing the head of the child. The treatment consists in removing the whole hair of the head with a razor, applying a large quantity of resinous ointment at bed time, in order to soften the attachments of the crusts, which, on the following morning, are to be washed off with soft brown soap and warm water. The ulceration is then to be treated with the same escbarotic lotions and ointment, as recommended under the simple phagedenic ulcer. Pure nitrate of silver is the most prompt remedy. This ulcer ation is also considered constitutional, and even infectious by many authors; but it can be no more constitutional than noli me tangere, and to consider it infectious appears truly ludicrous; but its con tagious character is completely established. In the application of escharotics to the scalp, we must attend to their stimulating effects upon the brain. Porrigo scutulata, or herpes circinatus, or ring worm, attacks the scalp, face, and neck, in the form of separate patches, of an irregular circular shape, resembling the fairy rings made by some of the fungi, from which it derives its name. It begins with clusters of small light yellow pustules, which soon break and form scabs or scales, beneath which a delicate ulceration is perceptible. When neglected, it spreads all over the head in the form of clustered patches. The treatment is precisely the same as that for tinea capitis, and is frequently as obstinate to cure. A variety of remedies are re commended by authors for both of these ulcerations.
Gangrenous phagedenic ulcer, or hospital gan grene, named also malignant ulcer, putrid ulcer, sloughing sore, contagious gangrene, phagedena gangrenosa, gangrene humide des hopitaux, and pourriture d'hopital. It is divided by some authors into two, and by others into four varieties, which is evidently superfluous. This ulceration attacks all kinds of ulcers, wounds, and even blistered surfaces, in hospitals, ships, and in low crowded filthy situa tions; and the smaller the sore, the more liable is it to be affected. The ulcer or wound becomes covered with a dirty white coloured slough, or a tenacious viscid ash-coloured matter, the secretion being checked; the edges are surrounded with an erysipelatous blush, and more or less adema. The patient feels little pain in the sore, which has more the sensation of a sting from a gnat; he is attacked with rigors, has a foul tongue, loaded constipated bowels, and excessive thirst, which soon form active fever. On the following day pro bably, the ulcer has sloughed all round, and may be double, or even quadruple, its original size, and in a few days becomes of such magnitude as to endanger his life. The edges and base of the
ulcer slough with alarming rapidity, the former becoming hardened, ragged, and everted, and having a most irregular shape, while the latter or granulations are large, tumid, and distended with gas. Small dark coloured vesicles appear on the sound skin surrounding the ulcer, which burst, and also form sloughing sores -.ultimately communicating with the original. The discharge is sanious, ichorous, viscid, emitting a peculiarly offensive odour. The patient now suffers con tinually from burning, lancinating pains. Fresh flabby blackish sloughs are rapidly formed, which overtop the ragged inflamed edges that are im mediately involved, until such an extent of ulcera tion is produced, as either to expose a number of blood-vessels, usually veins, which by repeated bleedings exhaust the patient, or the ulceration carries him off by the debility consequent on so great a source of irritation, or he dies of diarrhcea or hectic fever. Blood-vessels, particularly large arteries, do not generally yield so soon to this frightful ulceration as other textures. This ulcer is described to have occurred spontaneously; but it seems very doubtful if this ever occurs, for it is more probable that some source of irritation ex isted, as the pulling out of a hair of the skin, or the prick of a pin. Some authors contend that the febrile affection always precedes the ulceration, and if by this is meant, that a patient while affected with a simple ulcer or scratch is attacked with fever, which from the nature of the atmosphere, and the state of his constitution, assumes a very violent type, and readily disposes this trifling ulcer to acquire this gangrenous character, it is no doubt correct, as is satisfactorily proved by the cases of Blackadder. The lymphatic glands of the groin or axilla, whichever extremity is aflected, are generally excited early, and sometimes suppurate, and assume this phagedenic ulceration: while at other times they suppurate and heal kindly, while on other occasions again they merely become swollen. During this suppurative and healing pro cess, they suspend the phagedenic disposition of the original ulcer. By some authors it is stated that the syphilitic, cancerous, scrofulous, and variolous ulcers are not liable to be attacked with phagedena, an error very satisfactorily confuted by Drs. Thomson and Hennen. The treatment of this formidable disease, is by the vigorous use of the lancet in the beginning or inflammatory stage, and by repeating it as often as any inflammatory diathesis remains. The inflammatory action does not last long, in consequence of the great debili tating causes present; still, if we do not bleed during the inflammatory stage, the fever will con tinue to rage, and the ulceration will be the more extensive, and consequently the debility greater, which is clearly and satisfactorily proved by the various cases on record, and is daily evinced in the treatment of continued and typhus fevers. The propriety of blood-letting is supported by Drs. Trotter, Hennen, and Boggle. The application of the actual cautery to the ulcer, followed by hot dressings, and over these dry lint, tow, and the most gentle bandaging. What is termed the eighteen tailed bandage (see Plate DXV. Fig. 4), deserves to be preferred in such cases. The ulcer should be divested as much as possible of sloughs and moisture, previously to the application of the cautery, which should then be applied to every point, particularly the edges, and be repeated whenever there is the least tendency of the ulcer to spread. The actual cautery and compression are the only remedies for ulcerated arteries, as they will not bear the ligature, however remote from the diseased action, and a fresh wound would instan taneously assume the gangrenous action. The hot dressings should be applied as hot as the patient can bear them, and be removed whenever they are moistened with matter, which commonly occurs twice or thrice a day; and the sore at each renewal ought to be washed with a warm solution of the subcarbonate of potash. No sponge should be em ployed, but lint and tow substituted, which ought to be immediately burned, as cleanliness is of vital importance in the treatment. The bandages after being thoroughly washed, ought to be immersed in lime-water for some hours, a practice of very bene ficial consequence in hospitals. In the inflam matory stage the patient should be put into a hot bath once or twice a clay, or the vapour-bath can be administered in bed, or he can he sponged with hot water. If possible, his linens and bed clothes ought to be changed daily, and the most free ventilation permitted. His diet during the in flammatory stage should be mild, and consist chiefly of ripe fruits and succulent vegetables, if the season permits. Great debility is necessarily to be anticipated; therefore, whenever all inflam matory diathesis has been subdued, the diet must be rendered nourishing, with a liberal allowance of wine and porter, if the bowels are not relaxed. Large opiates and the sulphate of quinine should be given. Hospital gangrene is peculiarly liable to relapse, on which account the greatest attention should be paid to the patient until the wound or ulcer has completely cicatrized, and he is restored to perfect health. An extraordinary variety of re medies have been used in this ulceration, the most efficacious of which are, the concentrated or diluted mineral acids, the nitrates of copper or silver, or solutions of these, also the solutio arsenicalis. Amputation is inadmissible in this species of gan grene, in consequence of the violent inflammatory fever present, which makes it a case of mortifi cation arising from an internal cause. The daring and convincing experiments of Dr. Blackadder, and the narrative of Dr. Trotter, satisfactorily establish that it is not infectious, but its contagious nature cannot be disputed.