Chapter III: Part 3

In this genus of ulcers, the bottom of the sore seems to be paved with a number of small fleshy points, with minute interstices betwixt them, or surrounding their bases. These are of a red colour, with a slight shade of the purple, and are wet with a yellowish fluid, which is called pus; but which must of necessity differ from the fluid yielded by suppuration. This separates freely from the surface, when it is wiped or touched with a sponge, and then the granulations may be distinctly observed[47]. The margins are smooth, thin, and a very little rounded, that is to say, are almost imperceptibly raised above the granulations, a circumstance which is essential to this ulcer, because, were they both on the same level, it would show, that the cicatrizing process did not go on properly; for, whenever the granulations rise to the level of the surface, they ought instantly to form skin. This cicatrix, which extends gradually from the circumference to the centre, is of a pale red colour; but the integuments immediately beyond it are white, and of the natural appearance. Sometimes, from a slight deviation or imperfection, one spot of the disk rises to the level sooner than the rest; but, in this case, it immediately skins, and the cicatrix extends from this in the same way as from the circumference, until they both meet. The sore is free from pain, the only sensation being a slight degree of smarting, or itchiness.

[47] Whenever the discharge does not separate completely from the surface, when it is wiped, but part of it remains, like a film, or jelly, betwixt the granulations, or on particular spots, we may be sure that the action is not healthy.

The treatment of this ulcer is very simple; for, in most cases, it is only essentially necessary that we prevent the operation of hurtful causes. We defend the part, by covering it with a soft pledget of lint, and keep it warm. When the cicatrization has commenced, it may be assisted by using an ointment containing any harmless powder, in such a proportion as to form a paste or scab upon the part[48], by which we afford an artificial covering, which remains in close contact with the granulations; and, by thus bringing them nearly into the same circumstances as when skin is formed, the cicatrizing action is accelerated. The same effect is sometimes produced, by allowing the pus to form a scab over superficial sores, by exposing them to the air, without any covering.

[48] Simple ointment, rubbed up with a fourth part of its weight of finely levigated calamine, or flowers of zinc, makes a useful application. Mr. Bell recommends, amongst other remedies, a saturnine ointment; but, if this produces any specific operation, it must be a hurtful one, injuring the action.

Dry lint is a very useful application; but, as it is apt to stick to the granulations, and tear them, when tender, it ought always to be well moistened before removal, which should be attempted slowly.

Mild ointments, such as the simple cerate, are frequently employed; but they must be free from all rancidity, otherwise they fret the skin, or injure the sore. In general, they are less useful than dry lint. When we do employ them, they ought to be applied only to the granulations and cicatrix, and not to the sound skin. More frequently we use these ointments spread on a pledget of linen, to keep the dry lint on the sore.

Poultices are also recommended in these cases; but they possess no peculiar advantage, and are apt to make the part feeble, and more likely to break out again.

Moderate pressure, by keeping up the action, is generally of service; but it is still more necessary when the action begins to flag, or becomes stationary. In this case, a compress ought to be placed over the sore, and the whole member rolled firmly round with a cotton bandage or, what will be still more useful, the part should be encircled with strips, spread with adhesive plaster, in the way which will afterwards be mentioned. Pressure acts by taking away the condition of vacuity; it forms an artificial covering and interstices for the superficial granulations, by which the natural process of forming granulation and skin is greatly assisted. The parts are, in this way, not only more quickly formed, but also in greater perfection; and their powers of action are greater. The cure is therefore more permanent, and the part is not so apt to die, or ulcerate again, as when healed with simple dressings.

This practice, which is useful in ulcers which from the first are healthy, is still more necessary in curing those which were formerly diseased, but have now become healthy; because, in them, the action is still more apt to flag.

The healing of large healthy ulcers which succeed to wounds, &c. will also be much hastened, if we artificially diminish the size of the cavity, and procure contact. Whenever one part can be brought in contact with another, it ought to be done, if the figure and functions of the part be not thereby injured, or if pain be not produced by doing so.

The older authors, from a mistaken theory, never allowed the action to proceed uninterrupted, or never co-operated with it in a rational manner. In every ulcer, it was necessary, first, to digest, or suppurate it, which was done with turpentine, or basilicon; next it was to be deterged with turpentine, mixed with yolk of eggs, or by the red precipitate; then it was to be incarned by sarcotics, such as tincture of myrrh and aloes, balsam of Peru, frankincense, &c.; lastly, the surface was to be dried into a callus, with dragon’s blood, white-lead, chalk, &c. These plans have, however, been long laid aside; but some practitioners still advise the use of styptics and spirit of wine to produce a cicatrix; they forget, however, that skin is formed by a different process than corrugation.

The diet ought to be good, in all cases of ulcers; but spiritous liquors, and the irregularities of life, must be avoided.

In ulcers of the legs, if pressure be employed, rest is not absolutely requisite; but, if this be not used, no cure can be obtained, if the patient walk about. Even if the adhesive plaster be applied, we ought not to allow of so much motion as to produce fatigue, or any uneasiness in the sore.

The treatment, then, of this genus of ulcers, may be comprised in two aphorisms.

First, When the action is, from the first, healthy and vigorous, and is continuing so, all which is essentially necessary, is to defend the part, and prevent the operation of any cause which might injure the action, such as cold, too much heat, mechanical irritation, &c. This may be done, by applying a bit of dry lint, or a rag spread with simple ointment, and wrapping the limb round with a flannel roller. But, if the action begins to flag, as it often does in large ulcers, or if the process become stationary, we must then indispensibly have recourse to gentle pressure.

Second, When the action has, at any one period, been diseased, or too low, but has been restored to a proper state, we must of necessity continue gentle pressure, and treat the sore as if the action were stationary, although it may not be so.

GENUS II.

_Of the Indolent Ulcer._

In this genus, the action is diminished, and, consequently, rendered imperfect and diseased.

Indolent ulcers, like those of the next genus, are divisible into two species: First, that in which both parts of the ulcerative action, namely, the granulating and purulent, are equally diseased, and equally imperfectly performed: Second, that in which one part is more affected than another[49].

[49] The circumstance of one part of an ulcer being more affected than another, will be more fully noticed in considering the next genus, in which it is of more practical consequence. Ulcers generally belong to this species, before they assume the characters of the second (for they frequently change from one species, or genus, to another; in which case, the treatment must also be changed).

The first species is distinguished by the following symptoms, which appear in greater or less degrees, according to the diminution and imperfection of the action.

The granulations are pale, and imperfectly formed, partaking less of the firmness and organisation of the healthy fleshy granulations in proportion to the affection of the action. They are obtuse, and scarcely at all elevated; and, therefore, the surface loses its doted, or red pointed appearance. The discharge is thin, and of a whitish colour, at the same time that we frequently observe isolated spots of lymph interwoven here and there with the imperfect granulations. Although these granulations are said not to be elevated, yet the surface often exhibits a species of fungus; but the individual granulations are not elevated, or pointed. This fungus never rises higher than the twentieth part of an inch above the level of the surrounding skin[50], and often appears only at particular parts of the surface. It is pale, and somewhat of a gelatinous appearance. The pain is trifling.

[50] The cause why these granulations rise, even this trifling height, above the level of the skin, is the indolence of the action, which prevents a cuticle from being formed in due time.

In more advanced cases, the whole disk is covered with a thin layer of lymphatic substance, which adheres firmly, and gives the idea of a thin pellicle being thrown over the granulations, which are seen imperfectly and irregularly through it. The discharge is generally thin, like serum, and considerable[51]. The edges are hard and tumefied, sometimes of a light purple colour, at other times white[52]. The surrounding integuments are also hard and thickened, at least in old ulcers, and the veins are generally more or less varicose.

[51] Indolence of the action does not imply that the quantity of a discharge should be lessened, but only that its nature should be changed. In this species, the discharge is much the same in quantity as in a healthy ulcer of the same size, but its perfection is greatly less.

[52] Sometimes the granulating action and the cicatrizing one seems to be confounded, the surface exhibiting a fibrous fleshy appearance. This I have seen most frequently in the calf of the leg; but it may occur in other parts.

These appearances vary in degree from the soft pale surface, and thin whitish purulent discharge, with slightly thickened edges, to the state now described. The pain, when compared to the size of the ulcer, is not considerable.

This genus may occur, in a slight degree, in recent sores, from neglect, &c.; but it is chiefly after ulcers have been of long standing, that they assume these appearances in the greatest degree. They may then be said to have become chronic, or habitual; and, in many instances, it is absolutely impossible to restore the action to its natural state, and produce recovery[53].

[53] These ulcers, after long continuance, frequently induce a disease in the bones or muscles seated below them, as will afterwards be mentioned.

The second species is distinguished by the paleness and imperfection of the granulations, whilst the discharge is tolerably good; but it never can be equal to that of the healthy ulcer; because, when one part of the action is affected, the other is also more or less affected. This species does not require any more particular observation or remark, because it is to be treated exactly as the first, of which it is often just a slighter degree, or a forerunner; for it is frequently the first change which takes place in a healthy ulcer. When it becomes diseased, it does not continue long; for both parts soon come to suffer in the same proportion; in which case, the ulcer belongs to the first species. For this reason, we never find old ulcers belonging to this species.

Chronic ulcers sometimes induce a disease of the bones, &c. below; but, in this case, they generally are converted into a different genus. They also come naturally, in consequence of the great imperfection of their action, and the consequent want of power, to act beyond the due proportion betwixt action and power; and, therefore, most ulcers of this genus come at last, if neglected, to belong to the next.

The most effectual remedy for these ulcers is pressure. This has been long employed, by means of tight rollers wound round the limb, or by the laced stocking. But, of late, a more effectual method has been proposed, namely, a bandage of adhesive plaster, which applies itself closely to the surface, and produces a state of artificial contact and covering. This has been recommended by Dr. Darwin in the form of a many-tailed bandage, and by Mr. Baynton in the form of strips, wrapped round the limb. The following is the method of applying them: A strip of adhesive plaster, about an inch broad, and so long as to encircle the limb and cross at each end, is to be warmed, and the middle of it applied to that part of the limb which is exactly opposite to the sore; both ends are now to be brought forward, and one of them laid tightly over the under part of the sore (if it be so large as not to be covered with one strip), whilst the other is brought firmly over this from the opposite side, and doubled down upon it. The ends of the strip thus fold over each other at the ulcer. Another strip is then to be applied to the part of the sore contiguous to this which is not yet covered, and so on in succession, until the whole be covered. This is the best way of applying the strips, if the integuments be firm; but, if they be loose and yielding, it will be useful to push forward the loose skin from behind, with the strips, as we bring them forward; and, instead of laying down first one end, and then the other over it, make the two ends cross each other at the same time, and lay them down upon the skin, and not on each other, the under end covering the lower part of the sore, and the upper the part next it. The same strip, therefore, covers two portions of the surface, whereas, in the first way, it covered only one; but, in this case, the strip must be longer, as it must fairly cross the ulcer on each side, and be retained by sticking to the adjacent skin. When the ulcer is deep, the strip will press only on the margins; and, therefore, it will be useful to fill up the surface with a fold of soft lint. A thin cotton roller is now to be wound firmly round the limb, beginning at the extremity, and continuing the bandage to the next joint above the sore.

By this contrivance, we obtain a firm covering to the granulations, and bring a substance in contact with each individual. We then restore, as it were, the natural state of the parts, each granulation having a substance in contact with it; and a slight interstice is left between each, owing to their pointed structure. They become, therefore, similar, in this respect, to the organic particles of internal parts; on which account, healing goes on more quickly, and the organic particles, or granulations, are deposited in greater perfection, and with greater powers of action; for the unusual and morbid condition of exposure and want of contact is now removed. The same circumstances promote cicatrization, when the granulations have risen to a proper height. This is more evidently seen in the cure which is effected of the smaller ulcers, by dusting them with chalk, &c. or dressing them with an ointment made thick with some mild powder, by which a scab, or covering, is formed, which operates clearly independently of pressure. Pressure, applied with this view, ought to be moderate and permanent, and may be used with utility in almost every case of solution of continuity, however healthy the action may be. But, besides being of use in this way, pressure also produces a second set of effects, by mechanically exciting action in the part to which it is applied. Applied to the skin, it increases the cuticular action, and the skin is formed thicker. Applied to a weakened part, it increases the natural action of that part, and strengthens it: This is seen in the instance of debilitated muscles, &c. But, if the pressure be too great, then a morbid increase of action takes place, which even goes the length of inflammation, if the pressure be considerable; and this inflammation is either strong or weak, according as the pressure has operated; for, if many vessels be obstructed, as is commonly the case, then the power of the part is injured, and the action is weak; or, the same happens if pressure be applied in any manner to a weak part, or if the constitution be weak; as, for instance, from previous disease.

Pressure, applied to a part, increases in particular the functions of absorption and deposition. If moderate, these functions are moderately increased, and the structure of the part continues either the same, or it augments in size, as we observe, in the effects of walking, on the skin of the feet; but, if the pressure be greater, then these functions are morbidly increased, the particles are deposited imperfectly formed, and are as quickly taken up. The structure is therefore destroyed, and a vacuity formed. These effects are produced more easily upon diseased than healthy structures; because their powers of acting, and sustaining action, are less. Friction is in this respect similar to pressure.

From these remarks, we may understand the mechanical utility of pressure in the cure of ulcers; for, when in a proper degree, it causes the absorption and destruction of the callous edges, or diseased substance, and likewise makes, if moderate, the diseased granulations be taken up, and more healthy ones be formed. We may likewise perceive, that, if the degree be too great, the action will become of an inflammatory nature, and injury will be done. We are therefore frequently under the necessity of counteracting this hurtful effect; for, the degree of pressure which is requisite for answering the first intention in old sores, or inducing action, in consequence of bringing the granulations or particles into the natural state of being in contact with some body, or covered by it[54], is often attended with such mechanical irritation, that the one effect would destroy the other, unless we kept the action within due bounds, by applying cold to the part. In healthy ulcers, the pressure necessary to produce its first set of effects, or to accelerate healing, by producing contact, is so trifling, that no counteracting effect takes place by the production of the second set of effects; and, therefore, no cold requires to be applied: But, in old ulcers, the pressure must be greater; and, therefore, cold water must be constantly applied to the bandage over the sore, by means of a sponge. We thus indeed lessen the effects of pressure on the absorbing system, and, therefore, the callus will be longer of being destroyed; but we, on the other hand, prevent the action of the granulations from being rendered morbid.

[54] The degree of pressure necessary for producing this effect is proportioned to the susceptibility of the granulations, or organic particles, for receiving the impression of being in contact. When a part is healthy, the mere circumstance of juxtaposition is sufficient for this purpose; and, in a healthy ulcer, the weight of the body applied, such as powdered chalk, or plaster of Paris, or at least the gentle pressure of a stocking, or easy bandage, is all that is necessary. But, when the action is too low, and the granulations are consequently imperfect, both in their structure, power of acting, and capability of receiving impressions, the contact, in order to operate, must be nearer, and more complete; or, in other words, the pressure must be greater. In these cases, bandages not only act on the surface, but also on the parts below, and, therefore, increase the degree of contact of the newly-formed organic particles, and thus strengthen the part.

The good effects of pressure, applied in a degree proportioned to the effect which we wish to produce, and to the state of the sore, are so universal, that it is unnecessary to give any examples of its success and utility. But, at the same time, it must be observed, that in old ulcers, and even in many of a more recent date, which have been much neglected, no application whatever will produce an uninterrupted cure; for, after some time, it ceases to produce the same effect upon the action. The part seems, by continuance, to be less acted on by the agent; the action is less affected, and slowly returns to its former state of imperfection. It is therefore necessary, either that we from time to time increase the power of our application, or vary our remedies, whenever the process becomes stationary. The latter is generally the most effectual way; and the remedies which we alternate with the effects of pressure, are those of what have been called the stimulating kind; but which of the individuals of this division ought to be employed, cannot always be determined, because one succeeds better in a particular instance than in another. It would, however, be of much importance, to ascertain which in general operated most effectually; because, if we employ one which does no positive good, we sustain positive harm; for the action is allowed to persevere in a retrograde process. I, therefore, paid particular attention to the operation of these applications, in the patients who were under my care in the Glasgow Infirmary.

Heat is found to increase almost every action; and, therefore, in indolent ulcers, it is sometimes of use, especially for a few days after we begin the management of the sore, as it paves the way for the action of other agents, by beginning a change of the action. Poultices are the vehicle by which it is most frequently applied, and answers, in general, better than other forms. Fomentations are much used by many practitioners, who employ decoctions of different kinds of vegetables; but they have no superiority over poultices. Dry heat was used by M. Hevin, who held ignited charcoal near the sore; and it is sometimes of use to repeat this practice betwixt each dressing.

Electricity is of little service; because it cannot be constantly employed; and, therefore, its operation is only temporary.

It is worthy of observation, that although this kind of ulcer may be sometimes completely cured by the use of heat, that yet the action is not so perfect, and consequently the structure and power of the part is weaker, than when stimulating dressings are employed. Exercise, or any other cause, is therefore more apt to injure the part afterwards, and make it again break out into an ulcer.

The red precipitate, mixed with resinous ointment, in the proportion of a drachm of the former to an ounce of the latter, is a very useful dressing; but the ung. hyd. nit. mixed with four times its weight of hog’s lard, forms an ointment which is still more generally useful.

Ten grains of the cuprum ammoniatum, rubbed up with an ounce of basilicon, or simple ointment, is sometimes useful, but cannot be depended on. The same may be said of an ointment composed of an ounce of ung. simplex, and ten drops of the oil of cloves, or of savin.

Cloths dipped in the aqua zinci vitriolati, or the solution of cuprum vitriolatum, diluted with water, so as only to smart moderately, are likewise of service, but not so frequently as weak solutions of the nitrates of silver, zinc, copper, bismuth, and many other metallic salts, such as muriate of mercury, &c.

Solution of common salt, or of nitre, of such a strength as to produce a moderate smarting, are of temporary advantage, but will not continue their effect long. Indeed all solutions of saline substances, whether alkaline or metallic, are most useful when applied only for half an hour at a time, when the sore is dressing.

Mixtures of Thus, elemi, turpentine, canadine balsam, &c. with wax, or oil, have no advantage over the common ung. resinosum[55].

[55] An ointment composed of these resinous substances is much recommended in the Acta Med. Berolin. Tom. VII. p. 58.

The bile, either by itself, or diluted, or mixed with yolk of eggs, does not seem to be of much service.

Lemon juice, or the mineral acids, particularly the nitrous, diluted so as to be of equal strength with the juice, are frequently of service[56]. Port wine is also an useful lotion.

[56] These acids coagulate the pus, and thus afford an artificial covering, or film, which remains in close contact with the granulations, and thus, by producing the natural circumstance of contact and covering, the effects of which have been already mentioned, as well as by creating a more vigorous action by their specific action, they frequently bring those sores into a healthy state.

Infusion of Cayenne pepper, in vinegar, added to water, in such a quantity as to smart, forms also a very useful application.

Of all these remedies, the ointments composed of the nitro-metallic salts, particularly the mercurial, are most generally useful: And the cure seems to be accelerated, by applying cloths dipped in weak solution of metallic salts, or weak acids, during the intervals of dressing. Whenever these applications fail, they must be dropped: And those which fail first, and soonest, seem to be the watery, or fluid applications; and, next to these, the simple resinous ointments.

These remedies generally produce their effect first at the margins. When this takes place, we must diminish the strength of the application at that part, in proportion to the activity of the action, which is marked by the redness and pointedness of the granulation, and the cicatrizing state. The circumference, and the rest of the surface, must, in this case, be dressed with different strips of linen, spread with different ointments. Soft linen, spread with simple cerate, or dry lint, which is preferable, should be applied to the cicatrix, and cicatrizing granulations, whilst a stimulating substance is applying to the rest of the surface.

When the surface is obstinately diseased, or the action very torpid and imperfect, caustic has been applied; but, although I have often used it, and even applied cloths dipped in solutions of metallic salts, so strong as to form an universal eschar, or slough, yet no benefit whatever was derived; for we do not thus change the nature of the action, but only remove a layer of the surface, and leave that below in possession of the same mode of action with the former. Caustic is more useful, when applied to callus edges; but even these are more effectually removed, by remedies which act more permanently, and gradually, particularly by pressure. The ancients used to extirpate these with the knife, but few will consent to its use. It is indeed more speedy and effectual than the caustic; but, unless the action be afterwards properly supported, it will be of no permanent service.

The hard and thickened state of the surrounding integuments, in old ulcers, is best moderated by pressure; but this must be long continued.

Varicose veins, were, by the ancients, considered as canals running into the sore, and furnishing the discharge; but, when we consider that these varices frequently occur without any ulceration, or discharge, the opinion must be abandoned. In such cases as occur alongst with ulceration, it will be more natural to consider the affection of the vein as a disease dependent originally on the ulcer, and induced by it, in the same way as the structure and functions of other neighbouring parts are changed and impaired by the continuance of a tedious and diseased ulcerative action. This state of the vein being once induced in any part of it, and even in a slight degree, two consequences follow: First, from the power or property of the vein being impaired, the blood is not duly propelled, but circulates slowly, and cannot overcome readily the weight of the blood above, which presses more powerfully, in consequence of the valves being rendered imperfect by the distension of the vessel. The disease, therefore, gradually increases; for, every day, the power of acting properly diminishes, at the same time that the mechanical necessity for acting, or the resistance of the column of blood increases. On account of the dilatation of the vessels, and the morbid or abortive effect to propel what they are unable to do, pain is produced, in the course of the varix, whenever the legs are kept in a dependent posture, or exercise is used. This pain is confounded with the uneasiness arising from the ulcer; and, therefore, these ulcers are said to be painful, and to be attended with pain in the course of the veins.

The second consequence is, that, as the veins which are more immediately connected with the ulcerated part, are diseased, and do not perform their part in the circulation properly, the functions of the part must be still more injured, and the varix, which originally perhaps was produced by the ulcer, comes in its turn to act on the sore, and prevent its healing; for the vein not acting properly, and conveying the blood fully, the action at the capillaries must be injured, and the artery and vein cannot act healthily. If this be the case, the power of forming granulations must be impeded, and these never can be deposited in the necessary degree of perfection.

Two modes of cure have been proposed, the one palliative, and the other radical. The first is effected by means of rollers, or bandages, which prevent the vein from being distended, and, therefore, enable it the better to carry on its circulatory function. In this way, we prevent, to a certain degree, the hurtful operation of the vein upon the ulcer, and are often enabled to heal it up. But, as we do not thus restore the vein to its natural powers, unless in young people, who continue the support or pressure for years, we can obtain no permanent cure of the varix; and very frequently the parts again ulcerate; because, whenever the pressure or support is withdrawn, and the patient walks about, then the function of the part becomes affected, the organic particles are not deposited in the same state of perfection, and the action which is induced by exercise causes the destruction of these granulations; or even the very circumstance of their being formed imperfectly is sufficient to produce their destruction, and the opening of the part; for all parts which have been formerly ulcerated are most ready to assume this action again, and the organic particles of that part are less perfect, and less able to bear action.

The second is obtained, by obliterating the diseased vein, or interrupting its communication with the trunk above, by which we make the blood take a different course, and be transmitted by healthy veins. If we now cure the sore, we find, that the same effects are produced as if we used permanent pressure; and, therefore, the functions of the part are more properly performed, and the organic particles possess greater power of acting, and sustaining action. The older surgeons proposed to effect the radical cure, by tying the vein at the two extremities of the diseased part, and cutting out the intercepted portion, or by laying it open, and digesting it, as they said. This, however, was, as they confess themselves, very seldom submitted to in ulcers of the legs; and was rather inserted to complete their treatises, than from a belief that the operation ought to be insisted on. Of late, it has been proposed by Mr. Home, to tie only the upper extremity of the diseased portion[57], by which adhesion takes place at that spot, and the circulation is there stopped. The pressure of the blood above is thus taken off, and the blood from below must circulate, in a greater degree, through vessels which are better able to perform their functions; and, therefore, the actions of the capillary vessels, whether nutrition, absorption, or conversion of the blood from arterial into veinous, must be more naturally performed. After the veins are tied, they gradually become smaller; for the pressure being permanently removed, the diseased veins can more fully propel their blood by lateral branches, at the same time that they receive less blood, more going by other vessels.

[57] This operation is performed by making an incision through the skin which covers the vena saphena below the knee; a ligature is then passed under the vessel, by means of a blunt needle, and the vessel is tied. In two or three days the ligature may be removed, its circle being previously divided with a pair of scissars.

It is a curious circumstance, that although ulcers may have remained in an indolent state for many years, and have become almost habitual, that yet, the cause of the indolence being removed, they recover their powers rapidly, and with very little assistance. Thus, when a varix, which originally was produced by the ulcer, reacts on the sore, and prevents it from healing, we find, that if this cause be removed, the ulcer frequently heals quickly, owing to the sudden removal of a principal cause of indolence, although a similar ulcer, without varices, would not be cured by the same application in the same time; because then all the usual causes of indolence would still remain to be removed, or their effects counteracted; but, in this case, having suddenly removed one great cause, the action rises so much, that it can overcome the rest, although, without this alleviation, the healing process would not be commenced, nor continued. It may be useful to attend to this circumstance in every case of indolent ulcers, whether attended by varices or not; because, if we can remove any particular cause, we do much toward producing a cure. Thus, callus edges, and diseased, or thickened integuments, &c. although originally dependent on the ulcer, yet react on it, and prevent it from healing. If, then, by pressure, or otherwise, we remove these causes, we accelerate the cure.

As an instance of the good effects of tying varices, I shall transcribe the following case from Mr. Home’s Observations: “A man, sixty years of age, had, for many years, gained his livelihood by going on messages, having been rendered unfit for any more laborious employment by a large ulcer on the left leg, just above the inner ankle. The complaint was of twelve years standing: It had been sometimes much better than at others, but had never been well during the whole of that period. In the year 1792, it became so bad as to confine him entirely. It was at this time I first saw him. Upon examining the limb, the veins were extremely large, and varicose; and the trunk of the vena saphena, at the knee, appeared almost the size of the little finger. The size of this vein led me to the idea of taking it up at that part, with a view of relieving the lower branches from the pressure of the blood, which I believed to be the cause why the parts remained weak, and the ulcer could not be healed. I explained my opinions upon this subject to the patient, and told him, that, if he thought it worth while to try it, I was very ready to do it for him. The man’s desire to get well was such as to induce him to embrace the offer of any mode of treatment which afforded the smallest chance of it. The vein was taken up in the way that I have mentioned: He complained of very little pain, no improper degree of inflammation was brought on by this operation, the ligature came away in nine days, and in fourteen the wound was healed.

“The ulcer upon the leg was dressed with dry lint; it put on a better appearance on the second day after the operation; on the fourteenth it had diminished in size one half; and in twenty-eight days was completely healed. He was also freed from a pain in the course of the veins of that leg, to which he had been subject for many years, whenever he used any exercise.

“He returned to his business of carrying messages, and called upon me a year after, perfectly well; his leg having continued sound.”

Issues have been proposed for the cure of this genus of ulcers; but, upon the principles which have been already mentioned, it must be evident, that they can be of little or no service; and, I am sure, that I never saw the smallest influence exerted by them over an ulcer. They are useful, however, after the ulcer is healed, by keeping up a secreting action, diminishing the risk of apoplexy, &c.; but then they ought never to be introduced until the sore be nearly healed, or until we have reason to suppose that the sore will heal, and that they will be required.

The treatment of this genus of ulcers may be comprised in the following aphorisms:

First, When the action of an ulcer becomes too low and imperfect, pressure is the best remedy for restoring it to its proper state, and for accelerating the cure.

Second, Whenever this ceases to produce any farther effect, or the action relapses, and begins to go backward, we must lay aside the pressure for a time, and dress the sore with some of the stimulating applications above mentioned, particularly the nitro-mercurial salts; and these, in their turn, must be laid aside, when they cease to produce a good effect, and the pressure be again had recourse to.

Third, When we use stimulating dressings, we must attend to the effects which they produce on different parts of the sore, and dress these differently, according to their condition. We must likewise proportion the strength of application to the state of the general action. Our remedies ought to smart most when the action is most torpid, and the smarting ought to continue longest; but, when the action has begun to be more perfect and vigorous, the same application will often be too strong.

Fourth, We must, in conjunction with this general plan, attend to particular morbid structures, which may be produced by the particular state of the ulcer, and which may react on it. The chronic thickness and hardness of the integuments, are best removed by pressure, and gentle frictions; but the restoration of the natural structure is very tedious. Callous edges are likewise best removed by pressure. When this fails, caustic must be repeatedly applied. Varicose veins may be palliated by firm bandages, but are, in general, after they have continued long, only to be cured by an operation.

Fifth, When chronic ulcers can be healed, it is useful to form an issue, in order to keep up the accustomed secretory action; but these issues have little effect in advancing the cure.

GENUS III.

_Of the overacting Ulcer._

This genus comprehends two species: First, that in which the granulating, or purulent process is morbidly increased, or the two parts of the ulcerative action, the granulating and the purulent, do not correspond, or bear the same proportion to each other that they do in a healthy ulcer: Second, that in which a state of general acute overaction takes place, both parts of the ulcerative action being equally affected, and rendered diseased.

For the illustration of the first species, I may remark, that there are some actions performed by particular parts of the body which are apparently simple; but there are others which are complicated, and consist evidently of different parts, which, in the aggregate, form a peculiar action, but which action may be modified according to the degree in which these different parts exist. Thus, there are various parts which, when taken together, form the inflammatory action, heat, redness, swelling, &c.; but these may, in certain cases, exist in different proportions. The ulcerative action is a complicated one, and consists of the secretory and organising action, or the purulent and granulating. These, in a healthy ulcer, bear a certain relation to each other, and are at all times so connected, that, when one part is injured, the other is also affected; but the one part may be affected more than the other. In the indolent ulcer, or that in which the action is too low, both parts are most commonly (at least after some time) equally affected, and a state of universal diminution, and consequent imperfection, takes place; but, in the beginning of this state, that is to say, when the healthy ulcer is first becoming diseased, and when the unhealthy condition has made little progress, it is not uncommon to observe an inequality in the action, or the granulations more affected than the discharge. In this genus of ulcers, however, the inequality is more striking, and frequently more permanent.

It is worthy of remark, that though the granulating action may be increased beyond the purulent one, that yet the purulent one never exists in a state of overaction without a correspondent affection of the granulating action; in which case, very different effects and symptoms are occasioned, and the second species of overacting ulcers is produced.

The first species has generally been described under the name of the fungous ulcer, or ulcer with hypersarcosis. The granulations are soft and indistinct. They are imperfectly formed, and, therefore, do not possess the pointed appearance which they exhibit in health; nor have they equal powers of action, nor longevity. They are formed quickly, and rise to a greater or less height above the level of the surrounding skin. The margins are generally soft, tumid, and of a dull red colour. The discharge, if there be no carious bone, is tolerably thick, and of a white colour, and not in greater quantity than would be yielded by a healthy ulcer of the same size: The quantity is even sometimes less. The pain, unless when a bone is diseased, is seldom considerable. This species admits of two varieties. In the first, the granulating process is increased, in consequence of some affection of the action, which is independent of any mechanical cause. In this case, the fungus is generally pretty firm, but commonly pale, and the discharge tolerably good. In the second variety, the granulating process is increased, in consequence of some mechanical irritation underneath, such as a piece of carious bone; and, in this case, the fungus is softer, and less firm; it is of a redder and more lively or fiery colour, and is sometimes covered, in particular parts, with spots of lymph; it bleeds upon the slightest touch. The sore is generally painful, and the discharge thin, serous, and of a fœtid smell, whilst we can frequently perceive at least one small foramen on the surface which leads down to the bone, and through which it may be felt to be rough. Out of this is discharged a thin matter from the bone, of a brownish colour, somewhat like soup, and more or less different from the discharge from the rest of the surface. These luxuriant granulations, however, must not be confounded with those which, at a later period, come from the bone itself, after it has begun to ulcerate. These are generally of a more florid red colour, though sometimes pale, and rise up either through chinks of the bare caries, or from such portions as are denuded by a previous exfoliation. They have, in general, a more pointed appearance than those which arise from the soft parts, so that, in many cases, the fungus resembles the surface of a strawberry, being rough. This variety may be induced quickly, the bone being injured, at the same time that the soft parts are affected; but, at other times, and perhaps more frequently, the bone becomes diseased, in consequence of the continuance of a simple ulcer immediately over it; as, for instance, on the tibia. In this case, the ulcer, which perhaps was formerly indolent, now changes its nature.

The second species exists in various degrees, and its symptoms admit of modification from the previous state of the ulcer. Sometimes an ulcer, although previously healthy, has its surface excited into a state of overaction, by exercise, or other causes. In this case, the sore becomes painful, and the granulations assume first a kind of light crimson colour, and then a brownish hue, from a species of mortification. They do not indeed become gangrenous, and slough, but they approach to a state nearly resembling death, and are absorbed. The edges are slightly erysipelatous, and the discharge watery. This may be called the first degree or stage of the disease; and the ulcer frequently recovers soon from this, and reassumes its healthy condition. But if it be neglected, or the injuring causes still continue, the state of overaction is increased, and becomes more perfect[58]; that is to say, the action which was injured in its different parts, and rendered unconnected by the incipient or new condition, becomes more completely and connectedly performed in its different parts, in an increased degree. The overacting state, which, in the first stage, took place, perhaps only for a few hours, or at least if it continued, did not rise to any great degree, or receive an augmentation in this stage, continues with violence, and generally with exacerbation. The granulations are absorbed almost as soon as they are deposited; because, owing to the overaction of the part, they are very imperfectly organised, and possess very little life and power of supporting action[59]. They evidently appear to be in a state of overaction; for they are fiery, and their colour, whether it be red or brownish, is bright or clear, and quite opposite to the dull hue which even the same colour may have in a different kind of sore. These bleed upon the slightest touch; on which account, the discharge is generally bloody. The margins are red and ragged, as if they were bitten by a mouse; and they are evidently in an ulcerating state. The surrounding skin is hot and erysipelatous, the discharge is thin and serous, and the pain great, generally somewhat of the burning kind. This sore, from the destruction of the granulations, and the propagation of a morbid degree of action, spreads as long as this condition continues; but the progress, as long as the ulcer belongs to this genus, or as granulations are formed, is not very rapid.

[58] By this I mean more perfect in its state of overaction.

[59] In highly overacting ulcers, the granulations seem to possess a middle state, betwixt proper organic particles and the morbid substance, called pus.

It not unfrequently happens, that, after a sore which has been indolent has begun to heal, it, from fatigue, or some less evident cause, has a state of overaction induced, in which case, different appearances are exhibited, according to the previous state of the sore. If it has begun to form a natural cicatrix, this gives way, the surface becomes livid, the discharge thin, and the pain considerable. A thin slough of the granulations is then generally formed, and comes off in portions mixed with the discharge. If this state be not checked, it frequently comes to exhibit the acute symptoms of the overacting ulcer which was last described. More frequently, however, it occurs when the sore is still indolent, and not in the healing state, and when the edges still remain callous, and the granulations foul and unhealthy. If, at this time, a disproportionate, or overaction be induced, by exercise or otherwise, we find, that the surface becomes dark and sloughy, the granulations flat and indistinct, the discharge is increased, and the margins become tumid, and of a modena colour, whilst the surrounding integuments are of a dull red mottled colour, or erythematous; and the foot, if it take place in the leg, is frequently cold, and the pain darts down to the toe.

This state is not unfrequently produced in old ulcers, by a disease of the parts below[60], which has been induced by the long continuance of the ulcer, which renders the bone carious, if it lie immediately under it (in which case, the first species of overacting ulcers is produced); but, at other times, by the sympathy of association, a diseased formative action (owing to the diseased formative action in the ulcer, or the imperfect granulations which are formed) is induced in the neighbouring parts, the muscles become pale, and have less of their fibrous texture, or the bone becomes rough, or pointed, like shagreen, and also becomes thickened, but without any appearance of caries. This diseased condition of the parts reacts on the ulcer, and induces overaction.

[60] This affection of the ulcer, produced by a disease of the parts below, is induced with a frequency nearly proportioned to the aptitude of the part below for becoming diseased, by the continuance of an ulcer over them. Tendons and bones are particularly apt to be injured in this way; and, therefore, ulcers seated over tendinous parts, or bones thinly covered, are more apt to affect these, and to be reacted on themselves, than when seated over fleshy parts. On the same account, ulcers on the foot, or ankle joint, are worse to heal than those a little farther up the leg; and the difference is greater than can be explained wholly, by the circumstance of distance from the heart, and possessing less power of performing action properly. Recent ulcers likewise heal easily on the feet, by proper treatment. It is old ulcers alone which are difficult to manage, and the cause is obvious.

This state of overacting may also be induced in old ulcers, without any malformation of the parts below, but merely in consequence of continuance; for, after an ulcer has remained long indolent, it comes to act so imperfectly, that it naturally goes beyond its power. This may be said to be a spontaneous change, or conversion of one genus into another.

We have then two varieties of this species: First, the state of overaction induced in an ulcer which was previously healthy; and this admits of two stages, the incipient and confirmed: The first sometimes consists only of one short paroxysm: The second continues for a longer time, and generally depends upon the neglect of the first attack. Second, the state of overaction induced in an ulcer which has previously been indolent; and this admits of two subdivisions, which arise from the condition of the ulcer at the time of its overacting, namely, whether it have been healing and cicatrizing, or the edges have been callus, and the action imperfect and morbid.

The observations on the cure of this genus of ulcers must naturally be arranged under the different species and varieties of these ulcers.

In the first variety of the first species, our object is to remove the supernumerary, or fungous granulations, and to replace them with others, which are formed more slowly, and in greater perfection.

Pressure, applied in the manner already explained, is one of the most useful remedies in this variety, and ought always to be tried first. The luxuriant granulations are quickly absorbed, and the succeeding ones are rendered more compact and healthy, and the cicatrix begins to be formed. If, however, we apply pressure in this, or indeed in any sore, to such a degree as to produce its specific effect, we must counteract its irritation by cold. If we do not, this sore is frequently converted into the second variety of the second species of this genus.

Caustic, and escharotics, have been sometimes applied to these sores; but they only remove a layer of granulations, without affecting the formation of the succeeding ones so much as some other remedies.

Stimulating applications are more useful; for, as they act more slowly, they produce a greater influence on the action.

The cuprum vitriolatum, mixed with simple ointment, in the proportion of a drachm to the ounce, is frequently serviceable; but the ung. hyd. nit. is still more useful. One drachm of this may be mixed with an ounce of hog’s lard and a scruple of camphor. Red precipitate, mixed with resinous ointment, is also often of service.

The application of powdered rheubarb is recommended by Mr. Home, and is frequently of service.

Lotions of port wine, solutions of white vitriol, or rose water, containing as many drops of l’eau mercurielle[61] as will make it moderately pungent, may be usefully applied before the dressing.

[61] L’eau mercurielle is a solution of mercury in nitrous acid.

Poultices seem to increase the diseased state; and mild dressings do not counteract it, but allow it to go on.