Part 7

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.

The second variety is only to be cured by removing the caries bone; but the same remedies which are used in the first variety may be employed here, as palliatives, or the means of preventing the ulcer from becoming worse. By a continuance of these applications, in cases of slight caries, a cure may, after some time, be obtained; for the thin layer of diseased bone, either comes away in fragments through an opening in the ulcer[62], or it is sometimes absorbed. This last event, the absorption of the bone, is particularly induced by pressure, applied by means of the adhesive plaster; and, therefore, where the disease is not extensive, it is always proper to have recourse to this; but if, upon trial, we find it to fail, or to convert the sore into the second species of this genus, which it sometimes does, we must omit it.

[62] In the description of this variety, it was mentioned, that there frequently was a small opening in the surface, which communicated with the bone; but, even where this is not the case, the layer of dead bone, when it exfoliates, comes through the granulations; for the granulations of the sound bone below raise it up, in consequence of which, pressure is made from within outward upon the ulcer, by which absorption is produced at that part, in a greater degree than deposition; and, therefore, a vacuity is produced.

As it is only in slight cases of caries that absorption of the bone is to be expected, we may consider it as necessary, in general, as a preparatory step toward healing, that the diseased portion of the bone be separated, and come away externally. It is therefore of advantage to endeavour to accelerate this; because, whatever does so, hastens the cure. Our attempts, with this view, are made at two different stages, and with different intentions. First, when the bone has separated, or exfoliated from the part below, by making an incision through the ulcerated surface, we remove the dead part, and allow the sore to heal. This stage may be discovered, by pushing a probe through the opening, if there be one, or through the granulations, down to the layer of bone, which we find to be elastic when we press on it. But, even although the incision be made before this stage has taken place, no harm is done, because it is of use in the first stage. Second, when the carious bone has not yet exfoliated, but remains in contact with the rest of the bone, ulceration of the sound part not having yet taken place, it will be useful to make an incision down to the bone, and, as soon as the bleeding stops, or lessens, to apply caustic freely, in the whole course of the incision, so as to act upon the caries, or rough portion; or we may use the trephine, or other remedies, which have been formerly mentioned. It sometimes happens, that the soft parts are, at particular portions, and often to a considerable extent, removed by absorption, and the bone, at these parts, is left bare. In this case, no incision is necessary, except occasionally through some bands of granulations which extend across the bare bone; and, therefore, we can at once apply our remedies to the bone, or make perforation with the trephine.

The second species requires to be treated differently, according to its varieties.

As the incipient stage of the first variety frequently consists of only one short paroxysm, it would often be unnecessary to have recourse to any peculiar treatment; but, as it is impossible, a priori, to say whether the state of evacuation is to continue, it is requisite, in every instance, to vary our treatment, and apply the proper remedies for the disease.

Poultices are frequently useful in this kind of ulcer, when the surface is dark coloured, and the integuments are not yet affected. They have sometimes an effect of checking the morbid state, if this be not already done; but they more generally promote the absorption of the morbid granulations, after which the surface becomes healthy. If, however, the action be still greater, and more permanent, then the ulcer is tending toward the confirmed, or perfect state of overaction, and poultices are not of equal service; they are even sometimes hurtful.