_Of the Indolent Ulcer._
In this genus, the action is diminished, and, consequently, rendered
imperfect and diseased.
Indolent ulcers, like those of the next genus, are divisible into two
species: First, that in which both parts of the ulcerative action,
namely, the granulating and purulent, are equally diseased, and equally
imperfectly performed: Second, that in which one part is more affected
than another[49].
[49] The circumstance of one part of an ulcer being more affected than
another, will be more fully noticed in considering the next genus, in
which it is of more practical consequence. Ulcers generally belong to
this species, before they assume the characters of the second (for they
frequently change from one species, or genus, to another; in which
case, the treatment must also be changed).
The first species is distinguished by the following symptoms, which
appear in greater or less degrees, according to the diminution and
imperfection of the action.
The granulations are pale, and imperfectly formed, partaking less
of the firmness and organisation of the healthy fleshy granulations
in proportion to the affection of the action. They are obtuse, and
scarcely at all elevated; and, therefore, the surface loses its doted,
or red pointed appearance. The discharge is thin, and of a whitish
colour, at the same time that we frequently observe isolated spots
of lymph interwoven here and there with the imperfect granulations.
Although these granulations are said not to be elevated, yet the
surface often exhibits a species of fungus; but the individual
granulations are not elevated, or pointed. This fungus never rises
higher than the twentieth part of an inch above the level of the
surrounding skin[50], and often appears only at particular parts of the
surface. It is pale, and somewhat of a gelatinous appearance. The pain
is trifling.
[50] The cause why these granulations rise, even this trifling height,
above the level of the skin, is the indolence of the action, which
prevents a cuticle from being formed in due time.
In more advanced cases, the whole disk is covered with a thin layer of
lymphatic substance, which adheres firmly, and gives the idea of a thin
pellicle being thrown over the granulations, which are seen imperfectly
and irregularly through it. The discharge is generally thin, like
serum, and considerable[51]. The edges are hard and tumefied, sometimes
of a light purple colour, at other times white[52]. The surrounding
integuments are also hard and thickened, at least in old ulcers, and
the veins are generally more or less varicose.
[51] Indolence of the action does not imply that the quantity of a
discharge should be lessened, but only that its nature should be
changed. In this species, the discharge is much the same in quantity as
in a healthy ulcer of the same size, but its perfection is greatly less.
[52] Sometimes the granulating action and the cicatrizing one seems to
be confounded, the surface exhibiting a fibrous fleshy appearance. This
I have seen most frequently in the calf of the leg; but it may occur in
other parts.
These appearances vary in degree from the soft pale surface, and thin
whitish purulent discharge, with slightly thickened edges, to the state
now described. The pain, when compared to the size of the ulcer, is not
considerable.
This genus may occur, in a slight degree, in recent sores, from
neglect, &c.; but it is chiefly after ulcers have been of long
standing, that they assume these appearances in the greatest degree.
They may then be said to have become chronic, or habitual; and, in many
instances, it is absolutely impossible to restore the action to its
natural state, and produce recovery[53].
[53] These ulcers, after long continuance, frequently induce a disease
in the bones or muscles seated below them, as will afterwards be
mentioned.
The second species is distinguished by the paleness and imperfection of
the granulations, whilst the discharge is tolerably good; but it never
can be equal to that of the healthy ulcer; because, when one part of
the action is affected, the other is also more or less affected. This
species does not require any more particular observation or remark,
because it is to be treated exactly as the first, of which it is often
just a slighter degree, or a forerunner; for it is frequently the first
change which takes place in a healthy ulcer. When it becomes diseased,
it does not continue long; for both parts soon come to suffer in the
same proportion; in which case, the ulcer belongs to the first species.
For this reason, we never find old ulcers belonging to this species.
Chronic ulcers sometimes induce a disease of the bones, &c. below; but,
in this case, they generally are converted into a different genus.
They also come naturally, in consequence of the great imperfection of
their action, and the consequent want of power, to act beyond the due
proportion betwixt action and power; and, therefore, most ulcers of
this genus come at last, if neglected, to belong to the next.
The most effectual remedy for these ulcers is pressure. This has been
long employed, by means of tight rollers wound round the limb, or by
the laced stocking. But, of late, a more effectual method has been
proposed, namely, a bandage of adhesive plaster, which applies itself
closely to the surface, and produces a state of artificial contact and
covering. This has been recommended by Dr. Darwin in the form of a
many-tailed bandage, and by Mr. Baynton in the form of strips, wrapped
round the limb. The following is the method of applying them: A strip
of adhesive plaster, about an inch broad, and so long as to encircle
the limb and cross at each end, is to be warmed, and the middle of
it applied to that part of the limb which is exactly opposite to the
sore; both ends are now to be brought forward, and one of them laid
tightly over the under part of the sore (if it be so large as not to
be covered with one strip), whilst the other is brought firmly over
this from the opposite side, and doubled down upon it. The ends of
the strip thus fold over each other at the ulcer. Another strip is
then to be applied to the part of the sore contiguous to this which is
not yet covered, and so on in succession, until the whole be covered.
This is the best way of applying the strips, if the integuments be
firm; but, if they be loose and yielding, it will be useful to push
forward the loose skin from behind, with the strips, as we bring them
forward; and, instead of laying down first one end, and then the other
over it, make the two ends cross each other at the same time, and lay
them down upon the skin, and not on each other, the under end covering
the lower part of the sore, and the upper the part next it. The same
strip, therefore, covers two portions of the surface, whereas, in the
first way, it covered only one; but, in this case, the strip must be
longer, as it must fairly cross the ulcer on each side, and be retained
by sticking to the adjacent skin. When the ulcer is deep, the strip
will press only on the margins; and, therefore, it will be useful to
fill up the surface with a fold of soft lint. A thin cotton roller is
now to be wound firmly round the limb, beginning at the extremity, and
continuing the bandage to the next joint above the sore.
By this contrivance, we obtain a firm covering to the granulations, and
bring a substance in contact with each individual. We then restore,
as it were, the natural state of the parts, each granulation having a
substance in contact with it; and a slight interstice is left between
each, owing to their pointed structure. They become, therefore,
similar, in this respect, to the organic particles of internal parts;
on which account, healing goes on more quickly, and the organic
particles, or granulations, are deposited in greater perfection, and
with greater powers of action; for the unusual and morbid condition of
exposure and want of contact is now removed. The same circumstances
promote cicatrization, when the granulations have risen to a proper
height. This is more evidently seen in the cure which is effected of
the smaller ulcers, by dusting them with chalk, &c. or dressing them
with an ointment made thick with some mild powder, by which a scab, or
covering, is formed, which operates clearly independently of pressure.
Pressure, applied with this view, ought to be moderate and permanent,
and may be used with utility in almost every case of solution of
continuity, however healthy the action may be. But, besides being
of use in this way, pressure also produces a second set of effects,
by mechanically exciting action in the part to which it is applied.
Applied to the skin, it increases the cuticular action, and the skin is
formed thicker. Applied to a weakened part, it increases the natural
action of that part, and strengthens it: This is seen in the instance
of debilitated muscles, &c. But, if the pressure be too great, then a
morbid increase of action takes place, which even goes the length of
inflammation, if the pressure be considerable; and this inflammation
is either strong or weak, according as the pressure has operated;
for, if many vessels be obstructed, as is commonly the case, then the
power of the part is injured, and the action is weak; or, the same
happens if pressure be applied in any manner to a weak part, or if the
constitution be weak; as, for instance, from previous disease.
Pressure, applied to a part, increases in particular the functions of
absorption and deposition. If moderate, these functions are moderately
increased, and the structure of the part continues either the same, or
it augments in size, as we observe, in the effects of walking, on the
skin of the feet; but, if the pressure be greater, then these functions
are morbidly increased, the particles are deposited imperfectly
formed, and are as quickly taken up. The structure is therefore
destroyed, and a vacuity formed. These effects are produced more easily
upon diseased than healthy structures; because their powers of acting,
and sustaining action, are less. Friction is in this respect similar to
pressure.
From these remarks, we may understand the mechanical utility of
pressure in the cure of ulcers; for, when in a proper degree, it causes
the absorption and destruction of the callous edges, or diseased
substance, and likewise makes, if moderate, the diseased granulations
be taken up, and more healthy ones be formed. We may likewise
perceive, that, if the degree be too great, the action will become of
an inflammatory nature, and injury will be done. We are therefore
frequently under the necessity of counteracting this hurtful effect;
for, the degree of pressure which is requisite for answering the
first intention in old sores, or inducing action, in consequence of
bringing the granulations or particles into the natural state of being
in contact with some body, or covered by it[54], is often attended
with such mechanical irritation, that the one effect would destroy
the other, unless we kept the action within due bounds, by applying
cold to the part. In healthy ulcers, the pressure necessary to produce
its first set of effects, or to accelerate healing, by producing
contact, is so trifling, that no counteracting effect takes place
by the production of the second set of effects; and, therefore, no
cold requires to be applied: But, in old ulcers, the pressure must be
greater; and, therefore, cold water must be constantly applied to the
bandage over the sore, by means of a sponge. We thus indeed lessen the
effects of pressure on the absorbing system, and, therefore, the callus
will be longer of being destroyed; but we, on the other hand, prevent
the action of the granulations from being rendered morbid.
[54] The degree of pressure necessary for producing this effect is
proportioned to the susceptibility of the granulations, or organic
particles, for receiving the impression of being in contact. When a
part is healthy, the mere circumstance of juxtaposition is sufficient
for this purpose; and, in a healthy ulcer, the weight of the body
applied, such as powdered chalk, or plaster of Paris, or at least
the gentle pressure of a stocking, or easy bandage, is all that is
necessary. But, when the action is too low, and the granulations are
consequently imperfect, both in their structure, power of acting, and
capability of receiving impressions, the contact, in order to operate,
must be nearer, and more complete; or, in other words, the pressure
must be greater. In these cases, bandages not only act on the surface,
but also on the parts below, and, therefore, increase the degree of
contact of the newly-formed organic particles, and thus strengthen the
part.
The good effects of pressure, applied in a degree proportioned to the
effect which we wish to produce, and to the state of the sore, are so
universal, that it is unnecessary to give any examples of its success
and utility. But, at the same time, it must be observed, that in old
ulcers, and even in many of a more recent date, which have been much
neglected, no application whatever will produce an uninterrupted
cure; for, after some time, it ceases to produce the same effect upon
the action. The part seems, by continuance, to be less acted on by
the agent; the action is less affected, and slowly returns to its
former state of imperfection. It is therefore necessary, either that
we from time to time increase the power of our application, or vary
our remedies, whenever the process becomes stationary. The latter is
generally the most effectual way; and the remedies which we alternate
with the effects of pressure, are those of what have been called the
stimulating kind; but which of the individuals of this division ought
to be employed, cannot always be determined, because one succeeds
better in a particular instance than in another. It would, however,
be of much importance, to ascertain which in general operated most
effectually; because, if we employ one which does no positive good,
we sustain positive harm; for the action is allowed to persevere in
a retrograde process. I, therefore, paid particular attention to the
operation of these applications, in the patients who were under my care
in the Glasgow Infirmary.
Heat is found to increase almost every action; and, therefore, in
indolent ulcers, it is sometimes of use, especially for a few days
after we begin the management of the sore, as it paves the way for the
action of other agents, by beginning a change of the action. Poultices
are the vehicle by which it is most frequently applied, and answers, in
general, better than other forms. Fomentations are much used by many
practitioners, who employ decoctions of different kinds of vegetables;
but they have no superiority over poultices. Dry heat was used by M.
Hevin, who held ignited charcoal near the sore; and it is sometimes of
use to repeat this practice betwixt each dressing.
Electricity is of little service; because it cannot be constantly
employed; and, therefore, its operation is only temporary.
It is worthy of observation, that although this kind of ulcer may be
sometimes completely cured by the use of heat, that yet the action is
not so perfect, and consequently the structure and power of the part is
weaker, than when stimulating dressings are employed. Exercise, or any
other cause, is therefore more apt to injure the part afterwards, and
make it again break out into an ulcer.
The red precipitate, mixed with resinous ointment, in the proportion
of a drachm of the former to an ounce of the latter, is a very useful
dressing; but the ung. hyd. nit. mixed with four times its weight of
hog’s lard, forms an ointment which is still more generally useful.
Ten grains of the cuprum ammoniatum, rubbed up with an ounce of
basilicon, or simple ointment, is sometimes useful, but cannot be
depended on. The same may be said of an ointment composed of an ounce
of ung. simplex, and ten drops of the oil of cloves, or of savin.
Cloths dipped in the aqua zinci vitriolati, or the solution of cuprum
vitriolatum, diluted with water, so as only to smart moderately, are
likewise of service, but not so frequently as weak solutions of the
nitrates of silver, zinc, copper, bismuth, and many other metallic
salts, such as muriate of mercury, &c.
Solution of common salt, or of nitre, of such a strength as to produce
a moderate smarting, are of temporary advantage, but will not continue
their effect long. Indeed all solutions of saline substances, whether
alkaline or metallic, are most useful when applied only for half an
hour at a time, when the sore is dressing.
Mixtures of Thus, elemi, turpentine, canadine balsam, &c. with wax, or
oil, have no advantage over the common ung. resinosum[55].
[55] An ointment composed of these resinous substances is much
recommended in the Acta Med. Berolin. Tom. VII. p. 58.
The bile, either by itself, or diluted, or mixed with yolk of eggs,
does not seem to be of much service.
Lemon juice, or the mineral acids, particularly the nitrous, diluted
so as to be of equal strength with the juice, are frequently of
service[56]. Port wine is also an useful lotion.
[56] These acids coagulate the pus, and thus afford an artificial
covering, or film, which remains in close contact with the
granulations, and thus, by producing the natural circumstance of
contact and covering, the effects of which have been already mentioned,
as well as by creating a more vigorous action by their specific action,
they frequently bring those sores into a healthy state.
Infusion of Cayenne pepper, in vinegar, added to water, in such a
quantity as to smart, forms also a very useful application.
Of all these remedies, the ointments composed of the nitro-metallic
salts, particularly the mercurial, are most generally useful: And
the cure seems to be accelerated, by applying cloths dipped in weak
solution of metallic salts, or weak acids, during the intervals of
dressing. Whenever these applications fail, they must be dropped: And
those which fail first, and soonest, seem to be the watery, or fluid
applications; and, next to these, the simple resinous ointments.
These remedies generally produce their effect first at the margins.
When this takes place, we must diminish the strength of the application
at that part, in proportion to the activity of the action, which is
marked by the redness and pointedness of the granulation, and the
cicatrizing state. The circumference, and the rest of the surface,
must, in this case, be dressed with different strips of linen, spread
with different ointments. Soft linen, spread with simple cerate, or
dry lint, which is preferable, should be applied to the cicatrix, and
cicatrizing granulations, whilst a stimulating substance is applying
to the rest of the surface.
When the surface is obstinately diseased, or the action very torpid
and imperfect, caustic has been applied; but, although I have often
used it, and even applied cloths dipped in solutions of metallic salts,
so strong as to form an universal eschar, or slough, yet no benefit
whatever was derived; for we do not thus change the nature of the
action, but only remove a layer of the surface, and leave that below
in possession of the same mode of action with the former. Caustic is
more useful, when applied to callus edges; but even these are more
effectually removed, by remedies which act more permanently, and
gradually, particularly by pressure. The ancients used to extirpate
these with the knife, but few will consent to its use. It is indeed
more speedy and effectual than the caustic; but, unless the action be
afterwards properly supported, it will be of no permanent service.
The hard and thickened state of the surrounding integuments, in old
ulcers, is best moderated by pressure; but this must be long continued.
Varicose veins, were, by the ancients, considered as canals running
into the sore, and furnishing the discharge; but, when we consider that
these varices frequently occur without any ulceration, or discharge,
the opinion must be abandoned. In such cases as occur alongst with
ulceration, it will be more natural to consider the affection of the
vein as a disease dependent originally on the ulcer, and induced by it,
in the same way as the structure and functions of other neighbouring
parts are changed and impaired by the continuance of a tedious and
diseased ulcerative action. This state of the vein being once induced
in any part of it, and even in a slight degree, two consequences
follow: First, from the power or property of the vein being impaired,
the blood is not duly propelled, but circulates slowly, and cannot
overcome readily the weight of the blood above, which presses more
powerfully, in consequence of the valves being rendered imperfect
by the distension of the vessel. The disease, therefore, gradually
increases; for, every day, the power of acting properly diminishes,
at the same time that the mechanical necessity for acting, or the
resistance of the column of blood increases. On account of the
dilatation of the vessels, and the morbid or abortive effect to propel
what they are unable to do, pain is produced, in the course of the
varix, whenever the legs are kept in a dependent posture, or exercise
is used. This pain is confounded with the uneasiness arising from the
ulcer; and, therefore, these ulcers are said to be painful, and to be
attended with pain in the course of the veins.
The second consequence is, that, as the veins which are more
immediately connected with the ulcerated part, are diseased, and do
not perform their part in the circulation properly, the functions of
the part must be still more injured, and the varix, which originally
perhaps was produced by the ulcer, comes in its turn to act on the
sore, and prevent its healing; for the vein not acting properly, and
conveying the blood fully, the action at the capillaries must be
injured, and the artery and vein cannot act healthily. If this be the
case, the power of forming granulations must be impeded, and these
never can be deposited in the necessary degree of perfection.
Two modes of cure have been proposed, the one palliative, and the other
radical. The first is effected by means of rollers, or bandages, which
prevent the vein from being distended, and, therefore, enable it the
better to carry on its circulatory function. In this way, we prevent,
to a certain degree, the hurtful operation of the vein upon the ulcer,
and are often enabled to heal it up. But, as we do not thus restore the
vein to its natural powers, unless in young people, who continue the
support or pressure for years, we can obtain no permanent cure of the
varix; and very frequently the parts again ulcerate; because, whenever
the pressure or support is withdrawn, and the patient walks about, then
the function of the part becomes affected, the organic particles are
not deposited in the same state of perfection, and the action which
is induced by exercise causes the destruction of these granulations;
or even the very circumstance of their being formed imperfectly is
sufficient to produce their destruction, and the opening of the part;
for all parts which have been formerly ulcerated are most ready to
assume this action again, and the organic particles of that part are
less perfect, and less able to bear action.
The second is obtained, by obliterating the diseased vein, or
interrupting its communication with the trunk above, by which we make
the blood take a different course, and be transmitted by healthy veins.
If we now cure the sore, we find, that the same effects are produced as
if we used permanent pressure; and, therefore, the functions of the
part are more properly performed, and the organic particles possess
greater power of acting, and sustaining action. The older surgeons
proposed to effect the radical cure, by tying the vein at the two
extremities of the diseased part, and cutting out the intercepted
portion, or by laying it open, and digesting it, as they said. This,
however, was, as they confess themselves, very seldom submitted to
in ulcers of the legs; and was rather inserted to complete their
treatises, than from a belief that the operation ought to be insisted
on. Of late, it has been proposed by Mr. Home, to tie only the upper
extremity of the diseased portion[57], by which adhesion takes place
at that spot, and the circulation is there stopped. The pressure of the
blood above is thus taken off, and the blood from below must circulate,
in a greater degree, through vessels which are better able to perform
their functions; and, therefore, the actions of the capillary vessels,
whether nutrition, absorption, or conversion of the blood from arterial
into veinous, must be more naturally performed. After the veins are
tied, they gradually become smaller; for the pressure being permanently
removed, the diseased veins can more fully propel their blood by
lateral branches, at the same time that they receive less blood, more
going by other vessels.
[57] This operation is performed by making an incision through the skin
which covers the vena saphena below the knee; a ligature is then passed
under the vessel, by means of a blunt needle, and the vessel is tied.
In two or three days the ligature may be removed, its circle being
previously divided with a pair of scissars.
It is a curious circumstance, that although ulcers may have remained
in an indolent state for many years, and have become almost habitual,
that yet, the cause of the indolence being removed, they recover their
powers rapidly, and with very little assistance. Thus, when a varix,
which originally was produced by the ulcer, reacts on the sore, and
prevents it from healing, we find, that if this cause be removed,
the ulcer frequently heals quickly, owing to the sudden removal of
a principal cause of indolence, although a similar ulcer, without
varices, would not be cured by the same application in the same time;
because then all the usual causes of indolence would still remain to
be removed, or their effects counteracted; but, in this case, having
suddenly removed one great cause, the action rises so much, that it can
overcome the rest, although, without this alleviation, the healing
process would not be commenced, nor continued. It may be useful to
attend to this circumstance in every case of indolent ulcers, whether
attended by varices or not; because, if we can remove any particular
cause, we do much toward producing a cure. Thus, callus edges, and
diseased, or thickened integuments, &c. although originally dependent
on the ulcer, yet react on it, and prevent it from healing. If, then,
by pressure, or otherwise, we remove these causes, we accelerate the
cure.
As an instance of the good effects of tying varices, I shall transcribe
the following case from Mr. Home’s Observations: “A man, sixty years of
age, had, for many years, gained his livelihood by going on messages,
having been rendered unfit for any more laborious employment by a large
ulcer on the left leg, just above the inner ankle. The complaint was
of twelve years standing: It had been sometimes much better than at
others, but had never been well during the whole of that period. In
the year 1792, it became so bad as to confine him entirely. It was at
this time I first saw him. Upon examining the limb, the veins were
extremely large, and varicose; and the trunk of the vena saphena, at
the knee, appeared almost the size of the little finger. The size of
this vein led me to the idea of taking it up at that part, with a view
of relieving the lower branches from the pressure of the blood, which
I believed to be the cause why the parts remained weak, and the ulcer
could not be healed. I explained my opinions upon this subject to the
patient, and told him, that, if he thought it worth while to try it, I
was very ready to do it for him. The man’s desire to get well was such
as to induce him to embrace the offer of any mode of treatment which
afforded the smallest chance of it. The vein was taken up in the way
that I have mentioned: He complained of very little pain, no improper
degree of inflammation was brought on by this operation, the ligature
came away in nine days, and in fourteen the wound was healed.
“The ulcer upon the leg was dressed with dry lint; it put on a better
appearance on the second day after the operation; on the fourteenth
it had diminished in size one half; and in twenty-eight days was
completely healed. He was also freed from a pain in the course of
the veins of that leg, to which he had been subject for many years,
whenever he used any exercise.
“He returned to his business of carrying messages, and called upon me
a year after, perfectly well; his leg having continued sound.”
Issues have been proposed for the cure of this genus of ulcers; but,
upon the principles which have been already mentioned, it must be
evident, that they can be of little or no service; and, I am sure,
that I never saw the smallest influence exerted by them over an ulcer.
They are useful, however, after the ulcer is healed, by keeping up a
secreting action, diminishing the risk of apoplexy, &c.; but then they
ought never to be introduced until the sore be nearly healed, or until
we have reason to suppose that the sore will heal, and that they will
be required.
The treatment of this genus of ulcers may be comprised in the
following aphorisms:
First, When the action of an ulcer becomes too low and imperfect,
pressure is the best remedy for restoring it to its proper state, and
for accelerating the cure.
Second, Whenever this ceases to produce any farther effect, or the
action relapses, and begins to go backward, we must lay aside the
pressure for a time, and dress the sore with some of the stimulating
applications above mentioned, particularly the nitro-mercurial salts;
and these, in their turn, must be laid aside, when they cease to
produce a good effect, and the pressure be again had recourse to.
Third, When we use stimulating dressings, we must attend to the
effects which they produce on different parts of the sore, and dress
these differently, according to their condition. We must likewise
proportion the strength of application to the state of the general
action. Our remedies ought to smart most when the action is most
torpid, and the smarting ought to continue longest; but, when the
action has begun to be more perfect and vigorous, the same application
will often be too strong.
Fourth, We must, in conjunction with this general plan, attend to
particular morbid structures, which may be produced by the particular
state of the ulcer, and which may react on it. The chronic thickness
and hardness of the integuments, are best removed by pressure, and
gentle frictions; but the restoration of the natural structure is very
tedious. Callous edges are likewise best removed by pressure. When
this fails, caustic must be repeatedly applied. Varicose veins may
be palliated by firm bandages, but are, in general, after they have
continued long, only to be cured by an operation.
Fifth, When chronic ulcers can be healed, it is useful to form an
issue, in order to keep up the accustomed secretory action; but these
issues have little effect in advancing the cure.