Sometimes, after an abscess has burst, or been opened, it continues in a progressive state of amendment for some time, and then becomes stationary, continuing to discharge matter without healing. This either takes place from the whole surface, or from a particular part of it, forming a sinus, the treatment of which will afterwards be mentioned, being the same with those which succeed abscesses which are originally unhealthy.
After an abscess bursts, the proper application is a warm poultice32, which should be continued in general as long as there is any stool, or hard margin; that is to say, until the increased quantity of diseased organic particles, which were formed during the inflammation, be absorbed, and the vessels at that part have either assumed the suppurative or natural action. After this, the orifice ought to be covered with a slip of lint, and moderate pressure applied over the surface of the abscess33, by which the sides are kept in constant contact, and reunion is accelerated. Good diet is also necessary, for we thus increase the powers of recovery, or keep up a proper action, and renew the vital principle, the quantity of which has been lessened during the inflammation, both by the continuance of a state of overaction, and by the remedies which are employed to diminish the action; for a state of real and permanent weakness is thus induced.
It sometimes happens, that suppuration takes place very slowly, and the action seems to be performed with little vigour. In this case, if the abscess be allowed to burst of itself, we both lose time, and are often, in the end, disappointed in a cure, the healing process not taking place. It is therefore useful, in these cases, to have recourse to other agents besides heat. If the pain be trifling, and the suppuration be what may be called chronic, or approaching to it, we will perhaps succeed, by applying gentle pressure on the abscess, by means of a thin roller, and laying a warm poultice over this. But, when this fails to increase the action, we ought to pass a seton, by which we evacuate the matter, and keep up the subsequent action to a degree sufficient for producing recovery. In doing this, however, it is necessary to attend to the state of the tumor; because, if, in every instance, we pass it from the highest to the lowest part, we shall sometimes make the part give way in a third place. If, for instance, the abscess be much thinner at the apex than elsewhere, or, if the action have made considerable progress toward the surface, then the stimulus of the action increases the performance of the natural process which was going on, and the action continues to extend itself until the part gives way. In these cases, then, we ought to pass the seton from the thin part to the lowest part; and this, in general, will, from the sympathy of association, be sufficient to excite the action of the whole internal surface.
When we resolve to use the seton, the following is the easiest method of introducing it: Make a puncture with a lancet either into the upper, or the thinnest, and most prominent part of the tumor, according to circumstances; and, into this puncture, introduce, using the lancet as a directer, a probe, having a piece of tape passed through its eye. The lancet is then to be withdrawn, and the probe pushed down to the under part of the abscess, where its point will be felt under the skin. A small incision is here to be made upon the knob of the probe, which is next to be passed through, and the tape drawn after it. The matter is then to be slowly pressed out; the tape is to be folded; and the abscess bound up with a compress and roller, so as to make moderate pressure upon it. Next day, the dressings are to be removed, and a clean piece of the tape drawn through, after which, pressure is again to be applied.
The size of the tape, the time which the seton ought to be employed, and the degree of pressure to be used, must be regulated by backwardness of the action, and the imperfection of the healing process.
If, either from improper management, or the morbid condition of the action, the abscess, after it bursts spontaneously, or is opened by art, continue to suppurate, without undergoing the ulcerative action preparatory to healing, then we find, that either the sides remain quite separate, producing a cavity, extended more or less, or one particular portion remains open, forming a sinus. Both of these cases require a treatment, which, in its principle, is the same, namely, the indication of the ulcerative action.
In the first case34, we shall frequently succeed by means of the seton, especially if we use pressure alongst with it; for, by keeping the internal surface in close contact, we tend to check the purulent, or suppurative action, and produce organic particles35. We may also succeed, by using stimulating injections, of such a strength as to produce a moderate degree of smarting. Of this kind are, wine and water, solutions of white vitriol, corrosive sublimate, &c. These ought to be used frequently in the course of the day, and pressure employed during the intervals. Incision, or laying the part open, is, being the most severe, the last remedy which is to be had recourse to. Small chronic abscesses may be laid open during their whole diameter; but larger ones require only to be cut up for a certain length.
The second case, has generally been considered as a species of ulcer, and has been named the sinus ulcer; but, although the orifice may sometimes possess the diseased ulcerative action, yet the sinus itself still continues in the suppurative state, and, therefore, cannot heal. These sinuses depend, in different instances, upon very different causes, and, therefore, require a variation in the treatment. The most simple species of sinus may be called mechanical, and is produced by matter flowing from a neighbouring cavity, and which cannot be freely discharged: Thus, for instance, if a deep abscess open at the highest part, or at a point above the level of its bottom, the matter constantly oozes out, and keeps the canal open. This is most apt to occur, when abscesses are formed deep amongst muscular parts; in which case, although the matter point at the centre, yet an accumulation must take place below, and the matter must continue to be discharged by the aperture, when it becomes so abundant as to be raised to the level of the opening; or, being once raised, it continues to flow out. The cure of this may at first be attempted mechanically, by tight bandages, which press out the matter, and keep the sides in contact; but, if the disease have been of long duration, then, whatever may have been its nature at first, we find, that the suppurative action extends along the mechanical sinus, which then becomes affected with a chronic action; in which case, it becomes similar to the second species of sinus. We must, in this species, make an opening at the most dependent part, and employ the means which will be now mentioned in considering the second species, or that produced in consequence of the suppurative action becoming chronic or habitual, independent of any mechanical cause. This may take place, although the aperture have been originally in a proper place, and the matter, instead of being retained and keeping up the disease, shall have been regularly discharged. The case in which this is most likely to happen, is that in which the abscess has been very tedious in its progress, and the action has been, from the first, slow. The distinction betwixt this species, and those which remain to be mentioned, is founded upon the absence of the symptoms which they possess, and by our examination with the probe, which points out the cause and extent, and informs us whether we be near a bone. The orifice is flabby, and has the appearance of the indolent ulcer. The cure of these sinuses is to be attempted, by pressing out the matter by means of proper bandages, or by making a dependent opening, which is generally necessary, at the same time that we raise the action of the part to a proper degree, and render the suppurative action acute and vigorous; in which case, it naturally terminates in the ulcerative, and thus the part has its structure restored. This is most easily effected, by passing a seton, and applying a proper degree of pressure, diminishing the size of the seton gradually, and in proportion to the vigour of the action and the approximation toward health. When, from the situation of the sinus, we cannot pass a seton (which rarely happens in this species of sinus), injections of wine may be used frequently, and pressure applied during the intervals. When these means fail, which is seldom the case, the part should, if its structure permit, be laid open. If this sinus have remained long open, its surface, like that of the chronic abscess, becomes changed, and a coat is formed, like the cyst of a tumour. When this is thick and hard, the sinus has been called a fistula, and it has been deemed necessary to dissect out the tube; but it is in general sufficient to use the remedies which increase the vigour of the action, and make it run its natural progress; such as the seton, or a free incision, if the parts be superficial, or no considerable vessel or nerve runs the risk of being wounded.
The third species of sinus is that in which the suppurative action is kept up by the operation of some adventitious cause; such as a caries bone, diseased cartilage, or the lodgement of a foreign body; as, for instance, a ball, a splinter of wood, bit of cloth, &c. This species is distinguished by our feeling the extraneous body, or diseased bone, with the probe, and by the fungous protuberance, or papilla, which shoots out from the orifice. In addition to the method of curing other sinuses, we must here endeavour to remove the adventitious cause, which is generally very difficult to be done. If the foreign body be deep, or if the diseased bone lie deep, and the sinus be narrow, we can do little in this way; sometimes, indeed, by enlarging the external part, we can come at the foreign body with a pair of small forceps, and may extract it, or may accelerate the exfoliation of the diseased bone; but we can have no certainty of success. If, however, the sinus be superficial, which sometimes happens in caries of the tibia, &c. it ought, in every instance, to be fully laid open, and the bone exposed, and treated in the way immediately to be mentioned. When this cannot be done, we may sometimes, by conveying the proper remedies through a tube down to the bone, procure exfoliation; or may, by setons, injections, and pressure, procure a temporary cure; but, as long as the adventitious cause remains, we cannot expect a permanent recovery. It is observed, that sinuses, when they can be healed in these circumstances, break out again upon very trifling exertions, and very frequently are renewed, after a short interval, in spite of all our precautions; such as rest, warmth, &c.
A caries36 of the bone is at all times a disease which is difficult to manage, both on account of the mechanical obstacles which we have to overcome, and the slowness with which the affected parts perform their actions either of disease or recovery. The divisions of this disease have generally been taken from the appearance of the caries, and its extent. We have the dry caries, the worm-eaten caries, the spongy, or carnous caries, &c. and we have the deep and superficial. But, as the cure of these is to be conducted on the same principles in all of them, and as they are most probably different degrees of the same complaint, it will be more useful to divide them into those which affect bones lying deeply, and those which affect the more superficial bones; because these different cases are attended with very different circumstances and symptoms. The first is preceded by an abscess, which forms generally with much pain, runs its course slowly, and does not burst for a considerable time. When it does open, its sides do not ulcerate, at least universally, but a sinus remains, the mouth, or exposed part of which only, assumes the ulcerative action. The second is more rarely preceded by any abscess, but is either coeval with the ulcer of soft parts, (both being produced by mechanical violence) or it succeeds the ulcer, and is caused by it. This ulcer belongs to the third genus, and will be afterwards described.
In treating of the cure of caries, the first thing is, to determine by what means the disease of the bone may be removed; and, secondly, what modification our treatment must undergo, in consequence of the caries belonging to the first or second species. From the very earliest periods, we find the application of stimulating and corrosive remedies recommended in this disease. The actual cautery, euphorbium, mineral acids, scalding oil, the essential oils, and warm balsams, have been universally employed, and frequently alternated with rasping and perforating the bone. This proceeded from observing, that, on the one hand, mild applications had no effect, and, on the other, that the natural slowness of exfoliation was overcome by the use of these more powerful remedies. A caries of a bone is correspondent to a mortification of a soft part; and, therefore, it is impossible to restore the diseased part to health, or life. Our chief object, then, must be to prevent the disease from spreading, and to procure a speedy separation of the dead portion. The first is much less under our power than the second; for, it is most probable, that, in the majority of instances, at least of those of a simple nature, the disease, from the first, extends a certain length, affecting a portion of the bone, and that it afterwards makes very little progress. There is, however, a specific disease which affects the bone in common with the soft parts. The bone becomes rough, and suppurates; and the soft parts have a fiery appearance: This has been called the phagedenic caries. Cancer, scrophula, lues, and other specific actions, also spread after they are once induced. The second object is to be effected by such means as operate upon the vitality and action of the part, and those which act mechanically. Those which tend mechanically to remove the dead portion, are perforations down to the sound part, which we know has happened, by the bleeding which ensues; or, we may saw down this length with a trephine. We thus, by cutting off the communication of part of the diseased surface with the adjacent parts, kill it completely, sooner than could otherwise happen, and likewise stimulate the parts below to assume the ulcerative action, and throw it off. We may also sometimes be able to turn out these portions with a levator. Those which act more exclusively, by affecting the action of the part, are stimulating applications; such as heat, acids, &c. The actual cautery is so terrifying to the patient, that it is now laid aside; and it is likewise liable to this objection, that it may, by its operation on the neighbouring parts of the bone, produce disease in them. The potential cautery is more useful, and may frequently be employed with advantage, either in a solid form, as to callus, &c. or dissolved in water, and applied with a pencil37. M. Sue, in his notes to Ravaton’s Practique, &c. recommends l’eau mercurielle, or solution of mercury, in nitrous acid. By these means, the sound part below assumes the ulcerative action, its connection with the diseased portion is then destroyed, and reparation takes place. The ulcer of the bone is red, and its surface covered with innumerable granulations, which rise up to the level of the surrounding parts, after which a cicatrice is formed. These granulations in the bone are absorbed, and others more perfect are deposited in their place, until at last they become completely osseous38.
The next point which merits our attention, is the situation of the bone, and the circumstances which attend the caries. When superficial, a fungous ulcer is produced, and the modification which this situation requires in the application of the general plan will come afterwards to be attended to; the modification in the treatment which is required in sinuses has been mentioned above. It may here only be remarked, that, where the sinuses are superficial, they may be laid open, which will induce the ulcerative action in their course, and allow us to apply the proper remedies to the bone; but where they run deep, we must either allow the disease to run its natural progress, and treat the constitution according to the effects produced, or, by means of a canula, convey a piece of caustic to the diseased part, in the same way as we treat obstinate strictures of the urethra, &c. When, with the probe, we feel the bone loose, we may assist its exit with the forceps, or by enlarging part of the sinus, according to circumstances.
When these sinuses communicate with joints, and depend upon diseased cartilages, tendons, or articulating surfaces of the bones, we can do very little in the way of curing them by injections or incisions; because we cannot thus remove the disease of the joint, but may increase it. Issues placed over the joint, with rest, cleanliness, and good diet, country air, &c. are the remedies chiefly to be employed in these cases; or, if hectic be induced, and these remedies fail, we must remove the diseased part, if this, on account of its situation, be practicable. When, however, these sinuses are superficial, and depend upon tendons not immediately connected with the articulation, it may be useful to lay them open, and treat the disease of the tendons with caustic, like a caries of a bone, or with escharotics, and stimulating applications.
The fourth species of sinuses, are those where a specific action exists39, and prevents the healthy ulcerative action from forming. Of this kind is the scrophulous sinus, which is generally accompanied with a caries bone, or diseased cartilage, and, therefore, is a complicated sinus40. This is distinguished, where the bone is diseased, by a shining or polished red skin, like a cicatrix, surrounding the fungus papilla at the orifice of the sinus, or the scrophulous-looking sore which exists there. When no caries bone exists, we have no papilla, but only the diseased ulcer at the orifice. In both cases, there are generally the marks of a scrophulous habit. In the first case, we are to treat the sinus as if it were of the third species. In the second case, we are to treat it as if of the second, conjoining the proper remedies internally, as will be mentioned in considering the cure of scrophulous action. These sinuses, although healed, have a tendency to break out again, especially in the spring or summer.
The effects of the suppurative action upon the constitution, may be divided into those which are dependent upon the formation of the action, such as coldness, listlessness, &c. which are common to all new actions; and those which are peculiar to the action when fully formed. The first set requires no particular treatment, with an immediate reference to their removal; but their presence indicates the necessity of changing our method of cure, if we have not already done so. In conjunction with proper local applications, we must give light nourishing diet, with or without wine, according to the extent of the action and the weakness of the patient. Rest, and general warmth, are also necessary; but the heat ought not to be carried so far as to produce any considerable sensation, or sweating. Diaphoretics have been recommended41; but there does not appear to be any necessity for their exhibition; because the cold, and other symptoms which we intend to relieve, depend upon the state of the local action, and are only to be removed by fully forming this action. Heat will not cure this coldness, or shivering, when the action which causes it is extensive; but, on the contrary, will frequently increase it, by accelerating the formative process. The immediate effects, then, or the primary symptoms of suppuration, require no particular treatment, with a view to their own removal, but are to be attended to as marks which point out the necessity of a change of treatment, with a view to keep up the action which induces them, and to prevent it from producing bad consequences afterwards to the constitution. Sometimes, indeed, in delicate people, suppuration at this period produces hysterical symptoms, such as languor, flatulence, or sometimes starting, tremors, and hysteric paroxysms, more or less distinct. The slighter affections of this kind may be frequently removed by a little warm wine and water; the more severe, by anodynes, conjoined with aromatic waters.
The second set of symptoms, or effects, are those which have been already described under the name of hectic, the production of which has formerly been explained. This action, when slight, has been called weakness, and has been considered as dependent upon the quantity of the discharge; but, for the reasons formerly mentioned, this cannot be admitted. The cure of this state is to be attempted, by lessening the local action, at the same time that we give soups, and other articles of nourishing diet, with a moderate proportion of wine, if this do not quicken the pulse, and produce heat of the skin. Anodynes in the evening, by procuring rest, will also be useful; but none of these remedies will produce their proper effect, unless the patient respire a pure air. Bark is considered as useful in these cases; but, unless good diet be conjoined, it is not of much benefit. If, however, we give the means of increasing the quantity of vital power, bark, by inducing an action more nearly resembling the natural one, will be serviceable; but, for this purpose, it must be exhibited in full doses. It is from giving this medicine too sparingly, and in cases where other causes, tending to counteract its effects, such as poor diet, bad air, &c. are allowed to remain and operate, that bark has been brought into disrepute.
When the general action is very considerable, then the exquisite hectic is induced, and the situation of the patient becomes alarming. When the local action is simply the suppurative or ulcerative action, we may consider that the general disease is also simple, and are to attempt the cure by the remedies which have been just now mentioned. In conjunction with such local applications as tend to check the local action, we must have recourse to all those means which tend to strengthen or renew the natural action of the system in general; for which purpose, we must attend, in the first place, to all the particular functions, or individual parts; and, in the second, to the whole in the aggregate. Under the second head are included bark and wine, with moderate exercise42, and proper diet; in the choice of which, we must be directed by the nourishment which is yielded, and by the capability of digesting the articles which we employ. In general, milk, soups, and jellies, answer best. Under the first head are included such remedies as tend to promote digestion, such as steel, bitters, mineral acids, &c. although in general the bark will supersede their use. The state of the bowels must also be attended to, avoiding costiveness on the one hand, and diarrhœa on the other. The secretion of the skin must also be regulated, stopping the colliquative sweating, if possible, by getting up for some time when it commences43. Lessening the quantity of bed-clothes, for a few minutes, will also sometimes interrupt it; but when it has continued long, it can only be checked by removing the diseased action44. A full dose of the bark given before the accession of the sweat, may sometimes, by influencing the morbid action, prevent the discharge. The respiration must in particular be attended to; for, by breathing country and pure air, the action of respiration is more fully performed, and, consequently, the source of vitality is increased, and the effects of our other remedies are increased. The importance of a change of air can only be known by those who have observed how fast patients have recovered from operations when removed to the country, and clean lodgings, with well-aired beds, although before this they were daily sinking. Indeed no capital operation, which is likely to induce the suppurative action, ought to be performed, where cleanliness, and a free circulation of air, free from fœtor, cannot be procured.
It is not yet discovered that any remedy has a specific power of removing the hectic, or diseased formative action, more than the local purulent one45; and, therefore, we are obliged solely to trust to these already mentioned, which have a natural tendency to increase the healthy action, or induce one nearly similar to it, and especially to a proper local treatment, by which we remove the exciting cause.
When these remedies fail, and the disease seems to continue, or increase, in spite both of general and local remedies, then we must, if it be practicable, remove the diseased part by an operation; and, in doing so, we must remember, that delay beyond a certain period is dangerous; because the general action becomes so rooted, and the strength so reduced, that recovery cannot take place. Operating in these circumstances, therefore, can only hasten death. The wound will not unite nor heal, and the general action will continue unabated.
When the local action is specific, the general one is also different from the simple hectic; and, therefore the remedies which are useful in simple hectic will not be of equal advantage in these cases, unless a specific remedy be conjoined, as, for instance, mercury prudently exhibited in the venereal hectic, dependent upon a neglected local complaint. The most frequent instance of specific hectic is the scrophulous; for the cure of which we possess no remedy which acts with certainty. Whenever, therefore, the local complaint cannot be cured, and the hectic increases, we must, if possible, remove the diseased part46; after which, the general action, notwithstanding its specific nature, most commonly declines; but the constitution still remains, as formerly, scrophulous, or even more so than before. That this is the case, would appear from the following fact: If a person slightly scrophulous, although originally sprung from a scrophulous stock, or in whom the constitutional disease seems to be disappearing, in consequence of intermarriages, &c. has, by means of a local injury done to a joint, &c. the scrophulous action excited, and consequent hectic, that person will, after cure, have the tendency to scrophula stronger in him than formerly; and the disease will even frequently be communicated to his children with its original violence.
Suppuration is a natural termination of inflammation; and the ulcerative action is invariably induced by the suppurative, unless this remain chronic. The ulcerative action is to be considered as in part a restoration of the natural one; for we find, that it produces a restoration of the structure, granulations being formed by the vessels which formerly supplied the organic particles, whilst the interstitial vessels still yield a morbid fluid, called pus; but this they cease to do, whenever they again are placed in the natural situation; that is to say, whenever they become covered with the granulations, or are rendered interstitial. In proportion, then, as granulations are formed, a certain number of vessels are rendered interstitial, so that the discharge gradually diminishes, until at last it ceases; for, when we come to the formation of a cuticle, we have very few interstitial vessels left, the skin having naturally few. At this time, the one set of vessels having completed their action, and the part being restored, the other also resume their action, and a thin exhalent fluid is thrown out by the new cuticle, which keeps it soft and moist, and which is the natural insensible perspiration. The action of the two sets of vessels, then, is dependent on each other; and, whenever one is diseased, the other becomes also more or less so.
GENUS I.
From these remarks, as well as from those which were formerly made, it will appear, that a healthy ulcer has a natural tendency to heal, and that we ought only to be careful not to interrupt the natural progress, nor allow the action to flag.
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 observed47. 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.
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 part48, 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.
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.
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 another49.
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 skin50, and often appears only at particular parts of the surface. It is pale, and somewhat of a gelatinous appearance. The pain is trifling.
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 considerable51. The edges are hard and tumefied, sometimes of a light purple colour, at other times white52. The surrounding integuments are also hard and thickened, at least in old ulcers, and the veins are generally more or less varicose.
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 recovery53.
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 it54, 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.
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. resinosum55.
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 service56. Port wine is also an useful lotion.
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 portion57, 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.
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.