_Of the Healthy Ulcer._
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 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.