_Of the overacting Ulcer._
This genus comprehends two species: First, that in which the
granulating, or purulent process is morbidly increased, or the two
parts of the ulcerative action, the granulating and the purulent, do
not correspond, or bear the same proportion to each other that they
do in a healthy ulcer: Second, that in which a state of general acute
overaction takes place, both parts of the ulcerative action being
equally affected, and rendered diseased.
For the illustration of the first species, I may remark, that there
are some actions performed by particular parts of the body which are
apparently simple; but there are others which are complicated, and
consist evidently of different parts, which, in the aggregate, form
a peculiar action, but which action may be modified according to the
degree in which these different parts exist. Thus, there are various
parts which, when taken together, form the inflammatory action, heat,
redness, swelling, &c.; but these may, in certain cases, exist in
different proportions. The ulcerative action is a complicated one, and
consists of the secretory and organising action, or the purulent and
granulating. These, in a healthy ulcer, bear a certain relation to
each other, and are at all times so connected, that, when one part is
injured, the other is also affected; but the one part may be affected
more than the other. In the indolent ulcer, or that in which the action
is too low, both parts are most commonly (at least after some time)
equally affected, and a state of universal diminution, and consequent
imperfection, takes place; but, in the beginning of this state, that
is to say, when the healthy ulcer is first becoming diseased, and when
the unhealthy condition has made little progress, it is not uncommon to
observe an inequality in the action, or the granulations more affected
than the discharge. In this genus of ulcers, however, the inequality is
more striking, and frequently more permanent.
It is worthy of remark, that though the granulating action may be
increased beyond the purulent one, that yet the purulent one never
exists in a state of overaction without a correspondent affection of
the granulating action; in which case, very different effects and
symptoms are occasioned, and the second species of overacting ulcers is
produced.
The first species has generally been described under the name of the
fungous ulcer, or ulcer with hypersarcosis. The granulations are soft
and indistinct. They are imperfectly formed, and, therefore, do not
possess the pointed appearance which they exhibit in health; nor have
they equal powers of action, nor longevity. They are formed quickly,
and rise to a greater or less height above the level of the surrounding
skin. The margins are generally soft, tumid, and of a dull red colour.
The discharge, if there be no carious bone, is tolerably thick, and of
a white colour, and not in greater quantity than would be yielded by a
healthy ulcer of the same size: The quantity is even sometimes less.
The pain, unless when a bone is diseased, is seldom considerable. This
species admits of two varieties. In the first, the granulating process
is increased, in consequence of some affection of the action, which
is independent of any mechanical cause. In this case, the fungus is
generally pretty firm, but commonly pale, and the discharge tolerably
good. In the second variety, the granulating process is increased,
in consequence of some mechanical irritation underneath, such as a
piece of carious bone; and, in this case, the fungus is softer, and
less firm; it is of a redder and more lively or fiery colour, and is
sometimes covered, in particular parts, with spots of lymph; it bleeds
upon the slightest touch. The sore is generally painful, and the
discharge thin, serous, and of a fœtid smell, whilst we can frequently
perceive at least one small foramen on the surface which leads down to
the bone, and through which it may be felt to be rough. Out of this is
discharged a thin matter from the bone, of a brownish colour, somewhat
like soup, and more or less different from the discharge from the
rest of the surface. These luxuriant granulations, however, must not
be confounded with those which, at a later period, come from the bone
itself, after it has begun to ulcerate. These are generally of a more
florid red colour, though sometimes pale, and rise up either through
chinks of the bare caries, or from such portions as are denuded by a
previous exfoliation. They have, in general, a more pointed appearance
than those which arise from the soft parts, so that, in many cases,
the fungus resembles the surface of a strawberry, being rough. This
variety may be induced quickly, the bone being injured, at the same
time that the soft parts are affected; but, at other times, and perhaps
more frequently, the bone becomes diseased, in consequence of the
continuance of a simple ulcer immediately over it; as, for instance,
on the tibia. In this case, the ulcer, which perhaps was formerly
indolent, now changes its nature.
The second species exists in various degrees, and its symptoms admit
of modification from the previous state of the ulcer. Sometimes an
ulcer, although previously healthy, has its surface excited into a
state of overaction, by exercise, or other causes. In this case,
the sore becomes painful, and the granulations assume first a kind
of light crimson colour, and then a brownish hue, from a species of
mortification. They do not indeed become gangrenous, and slough, but
they approach to a state nearly resembling death, and are absorbed.
The edges are slightly erysipelatous, and the discharge watery. This
may be called the first degree or stage of the disease; and the
ulcer frequently recovers soon from this, and reassumes its healthy
condition. But if it be neglected, or the injuring causes still
continue, the state of overaction is increased, and becomes more
perfect[58]; that is to say, the action which was injured in its
different parts, and rendered unconnected by the incipient or new
condition, becomes more completely and connectedly performed in its
different parts, in an increased degree. The overacting state, which,
in the first stage, took place, perhaps only for a few hours, or at
least if it continued, did not rise to any great degree, or receive
an augmentation in this stage, continues with violence, and generally
with exacerbation. The granulations are absorbed almost as soon as
they are deposited; because, owing to the overaction of the part, they
are very imperfectly organised, and possess very little life and power
of supporting action[59]. They evidently appear to be in a state of
overaction; for they are fiery, and their colour, whether it be red or
brownish, is bright or clear, and quite opposite to the dull hue which
even the same colour may have in a different kind of sore. These bleed
upon the slightest touch; on which account, the discharge is generally
bloody. The margins are red and ragged, as if they were bitten by a
mouse; and they are evidently in an ulcerating state. The surrounding
skin is hot and erysipelatous, the discharge is thin and serous, and
the pain great, generally somewhat of the burning kind. This sore,
from the destruction of the granulations, and the propagation of a
morbid degree of action, spreads as long as this condition continues;
but the progress, as long as the ulcer belongs to this genus, or as
granulations are formed, is not very rapid.
[58] By this I mean more perfect in its state of overaction.
[59] In highly overacting ulcers, the granulations seem to possess
a middle state, betwixt proper organic particles and the morbid
substance, called pus.
It not unfrequently happens, that, after a sore which has been indolent
has begun to heal, it, from fatigue, or some less evident cause, has a
state of overaction induced, in which case, different appearances are
exhibited, according to the previous state of the sore. If it has begun
to form a natural cicatrix, this gives way, the surface becomes livid,
the discharge thin, and the pain considerable. A thin slough of the
granulations is then generally formed, and comes off in portions mixed
with the discharge. If this state be not checked, it frequently comes
to exhibit the acute symptoms of the overacting ulcer which was last
described. More frequently, however, it occurs when the sore is still
indolent, and not in the healing state, and when the edges still remain
callous, and the granulations foul and unhealthy. If, at this time, a
disproportionate, or overaction be induced, by exercise or otherwise,
we find, that the surface becomes dark and sloughy, the granulations
flat and indistinct, the discharge is increased, and the margins become
tumid, and of a modena colour, whilst the surrounding integuments are
of a dull red mottled colour, or erythematous; and the foot, if it take
place in the leg, is frequently cold, and the pain darts down to the
toe.
This state is not unfrequently produced in old ulcers, by a disease of
the parts below[60], which has been induced by the long continuance
of the ulcer, which renders the bone carious, if it lie immediately
under it (in which case, the first species of overacting ulcers is
produced); but, at other times, by the sympathy of association, a
diseased formative action (owing to the diseased formative action in
the ulcer, or the imperfect granulations which are formed) is induced
in the neighbouring parts, the muscles become pale, and have less of
their fibrous texture, or the bone becomes rough, or pointed, like
shagreen, and also becomes thickened, but without any appearance of
caries. This diseased condition of the parts reacts on the ulcer, and
induces overaction.
[60] This affection of the ulcer, produced by a disease of the parts
below, is induced with a frequency nearly proportioned to the aptitude
of the part below for becoming diseased, by the continuance of an ulcer
over them. Tendons and bones are particularly apt to be injured in
this way; and, therefore, ulcers seated over tendinous parts, or bones
thinly covered, are more apt to affect these, and to be reacted on
themselves, than when seated over fleshy parts. On the same account,
ulcers on the foot, or ankle joint, are worse to heal than those a
little farther up the leg; and the difference is greater than can be
explained wholly, by the circumstance of distance from the heart, and
possessing less power of performing action properly. Recent ulcers
likewise heal easily on the feet, by proper treatment. It is old ulcers
alone which are difficult to manage, and the cause is obvious.
This state of overacting may also be induced in old ulcers, without
any malformation of the parts below, but merely in consequence of
continuance; for, after an ulcer has remained long indolent, it comes
to act so imperfectly, that it naturally goes beyond its power. This
may be said to be a spontaneous change, or conversion of one genus into
another.
We have then two varieties of this species: First, the state of
overaction induced in an ulcer which was previously healthy; and
this admits of two stages, the incipient and confirmed: The first
sometimes consists only of one short paroxysm: The second continues for
a longer time, and generally depends upon the neglect of the first
attack. Second, the state of overaction induced in an ulcer which has
previously been indolent; and this admits of two subdivisions, which
arise from the condition of the ulcer at the time of its overacting,
namely, whether it have been healing and cicatrizing, or the edges have
been callus, and the action imperfect and morbid.
The observations on the cure of this genus of ulcers must naturally be
arranged under the different species and varieties of these ulcers.
In the first variety of the first species, our object is to remove
the supernumerary, or fungous granulations, and to replace them with
others, which are formed more slowly, and in greater perfection.
Pressure, applied in the manner already explained, is one of the most
useful remedies in this variety, and ought always to be tried first.
The luxuriant granulations are quickly absorbed, and the succeeding
ones are rendered more compact and healthy, and the cicatrix begins
to be formed. If, however, we apply pressure in this, or indeed in
any sore, to such a degree as to produce its specific effect, we
must counteract its irritation by cold. If we do not, this sore is
frequently converted into the second variety of the second species of
this genus.
Caustic, and escharotics, have been sometimes applied to these sores;
but they only remove a layer of granulations, without affecting the
formation of the succeeding ones so much as some other remedies.
Stimulating applications are more useful; for, as they act more slowly,
they produce a greater influence on the action.
The cuprum vitriolatum, mixed with simple ointment, in the proportion
of a drachm to the ounce, is frequently serviceable; but the ung. hyd.
nit. is still more useful. One drachm of this may be mixed with an
ounce of hog’s lard and a scruple of camphor. Red precipitate, mixed
with resinous ointment, is also often of service.
The application of powdered rheubarb is recommended by Mr. Home, and is
frequently of service.
Lotions of port wine, solutions of white vitriol, or rose water,
containing as many drops of l’eau mercurielle[61] as will make it
moderately pungent, may be usefully applied before the dressing.
[61] L’eau mercurielle is a solution of mercury in nitrous acid.
Poultices seem to increase the diseased state; and mild dressings do
not counteract it, but allow it to go on.
The second variety is only to be cured by removing the caries bone;
but the same remedies which are used in the first variety may be
employed here, as palliatives, or the means of preventing the ulcer
from becoming worse. By a continuance of these applications, in cases
of slight caries, a cure may, after some time, be obtained; for the
thin layer of diseased bone, either comes away in fragments through
an opening in the ulcer[62], or it is sometimes absorbed. This last
event, the absorption of the bone, is particularly induced by pressure,
applied by means of the adhesive plaster; and, therefore, where the
disease is not extensive, it is always proper to have recourse to this;
but if, upon trial, we find it to fail, or to convert the sore into the
second species of this genus, which it sometimes does, we must omit it.
[62] In the description of this variety, it was mentioned, that there
frequently was a small opening in the surface, which communicated
with the bone; but, even where this is not the case, the layer of
dead bone, when it exfoliates, comes through the granulations; for
the granulations of the sound bone below raise it up, in consequence
of which, pressure is made from within outward upon the ulcer, by
which absorption is produced at that part, in a greater degree than
deposition; and, therefore, a vacuity is produced.
As it is only in slight cases of caries that absorption of the bone
is to be expected, we may consider it as necessary, in general, as a
preparatory step toward healing, that the diseased portion of the bone
be separated, and come away externally. It is therefore of advantage to
endeavour to accelerate this; because, whatever does so, hastens the
cure. Our attempts, with this view, are made at two different stages,
and with different intentions. First, when the bone has separated,
or exfoliated from the part below, by making an incision through the
ulcerated surface, we remove the dead part, and allow the sore to
heal. This stage may be discovered, by pushing a probe through the
opening, if there be one, or through the granulations, down to the
layer of bone, which we find to be elastic when we press on it. But,
even although the incision be made before this stage has taken place,
no harm is done, because it is of use in the first stage. Second, when
the carious bone has not yet exfoliated, but remains in contact with
the rest of the bone, ulceration of the sound part not having yet taken
place, it will be useful to make an incision down to the bone, and, as
soon as the bleeding stops, or lessens, to apply caustic freely, in the
whole course of the incision, so as to act upon the caries, or rough
portion; or we may use the trephine, or other remedies, which have been
formerly mentioned. It sometimes happens, that the soft parts are, at
particular portions, and often to a considerable extent, removed by
absorption, and the bone, at these parts, is left bare. In this case,
no incision is necessary, except occasionally through some bands of
granulations which extend across the bare bone; and, therefore, we can
at once apply our remedies to the bone, or make perforation with the
trephine.
The second species requires to be treated differently, according to its
varieties.
As the incipient stage of the first variety frequently consists of only
one short paroxysm, it would often be unnecessary to have recourse to
any peculiar treatment; but, as it is impossible, a priori, to say
whether the state of evacuation is to continue, it is requisite, in
every instance, to vary our treatment, and apply the proper remedies
for the disease.
Poultices are frequently useful in this kind of ulcer, when the
surface is dark coloured, and the integuments are not yet affected.
They have sometimes an effect of checking the morbid state, if this
be not already done; but they more generally promote the absorption
of the morbid granulations, after which the surface becomes healthy.
If, however, the action be still greater, and more permanent, then the
ulcer is tending toward the confirmed, or perfect state of overaction,
and poultices are not of equal service; they are even sometimes hurtful.
Gentle pressure, accompanied with the use of cold water, is of service
in the same cases in which poultices are employed; that is to say, when
the action has not become perfect, but has rather begun to subside, and
the granulations remain dark coloured, and in a dying state. They are
absorbed, and replaced with more perfect and healthy granulations.
When, however, the action still continues in the same state of
overacting, or seems to be increasing, these remedies are rather
hurtful; and we will derive more benefit from using applications
of a gentle stimulating nature, which restore the action to a more
perfect and natural state, in the same way as they cure the inflammatio
debilis. For this purpose, one of the best applications is the
following:
R. Opii drachmas duas.
Camphoræ scrupulum.
Vini Albi uncias quatuor. Macera per triduum, dein cola.
This may be applied by means or a bit of lint to the sore. It generally
produces considerable smarting for a few minute, after which the pain
abates. The application is to be repeated every hour, or every two
hours, until the sore begins to look healthy, and the pain abates. The
adhesive plaster ought then to be substituted in its place.
Laudanum may also be employed with the same intention, but it is
inferior to the other.
Lemon juice is also sometimes useful, and may be employed where the
opiated wine fails, or is not at hand.
When the state of overaction becomes confirmed, and progressive, the
sore spreads, becomes very painful, and assumes the appearances which
have been already described. In this case, the application of carrot,
or turnip poultices, is frequently useful. These vegetables are
sometimes made into a poultice by boiling them, and, at other times, by
rasping them down raw.
Camomile flowers, boiled in milk, and then expressed, yield a
decoction, which, when made into a poultice with crumb of bread,
frequently abates the pain. Sometimes the application of cloths, dipped
in fine oil, give relief.
These sores are also frequently reduced to a more healthy state, by
applying cloths dipped in the following mixture:
R. Ammon. Hepatizatæ[63] guttas decem.
Aq. Font. uncias octo.
[63] The ammonia hepatizata is prepared by passing a stream of hepatic
gas through the aqua ammoniæ.
This produces a moderate degree of smarting for a little time, during
which the former painful sensation arising from the sore lessens, and
does not return for some time. When the peculiar pain of the ulcer
again manifests itself, the solution is again to be applied.
An ointment, consisting of two drachms of powdered opium, and one ounce
of simple cerate, is also a very useful application.
Sprinkling the sore with red precipitate, or touching the surface with
caustic, frequently stops the disease.
The kind of erythematous affection, which frequently affects the
surrounding skin, is best removed by stimulating applications, which
abate the pain or hot sensation, and make it less apt to ulcerate. The
following is a very useful application for this purpose. The affected
part is to be lightly dusted with it occasionally:
R. Hyd. Precip. Rub. unc. i.
Pulv. Opii semiunc.
Cretæ Ppt. unc. ii. Tere simul ut fiat pulvis subtiliss.
When, by any of these applications, the state of overaction is
overcome, pressure is the best remedy for preserving our ground, and
producing a cure; for, remedies which may be useful in the diseased
state, will be hurtful when this state is removed.
In this sore, anodynes are to be freely employed internally; for, given
sparingly, they do no good[64].
All the applications ought to be made gently, and lightly; because any
mechanical irritation increases the disease.
[64] No external application whatever will produce the same good
effect, if used by itself, as when such a general action is induced as
shall co-operate with the local remedies. In slight cases, thirty drops
of laudanum may be given twice a-day; but, when the overaction is more
violent, the dose must be more frequently repeated.
The second variety of this species is a very troublesome ulcer, and
admits, as has been already observed, of two divisions: First, it
not unfrequently happens, that, after an indolent ulcer has been in
a healing state for some time, a state of overaction is induced, by
fatigue, or other causes, particularly by the natural inability of
the newly formed, and not completely perfect granulations, to sustain
the action which is necessarily induced in them by their connection
with other parts (upon the principle of the communication of action).
In this case, the sore becomes foul, dark coloured, and painful,
whilst the cicatrix ulcerates, and the new granulations die, so
that, in a short time, the ulcer regains its original size, and even
spreads slowly to a greater extent. Second, an old ulcer may, without
having been previously in a healing state, become converted into the
overacting ulcer; because the surface has its power so weakened, that
common agents, which naturally excite action in the part, excite a
disproportioned and morbid action in the ulcer; but this action is
of the low kind, and bears somewhat the same relation to the first
species, (or overacting ulcerative action, in ulcers previously
healthy,) that the inflammatio debilis does to the inflammatio valida.
In this case, the surface is bloody, and the half-formed granulations
are of a livid colour; the callus edges are of a dusky red, or modena
colour; the integuments are generally mottled; the inferior part of the
limb is cold and painful.
In the cure of the first division, we must enjoin rest, as in the
second variety of the first species, and apply cloths, dipped in a
mixture of two parts of laudanum and one of camphorated spirit of
wine, which produces at first considerable smarting; but the sensation
is different from the former pain; and, although uneasy, is yet more
tolerable than the peculiar pain of the ulcer. This application ought
to be renewed two or three times in the course of the day, until the
surface becomes of a better appearance, and the pain abates.
The application of the powder of bark to these sores is sometimes, but
very seldom, of service[65].
[65] This was probably recommended on account of the sphacelated
appearance which these sores sometimes have.
A poultice, formed of decoction of camomile flowers, opium, and
charcoal[66], is frequently of use, and should be employed when the
laudanum and camphorated spirit fail. This should be applied cold.
[66] Let two ounces of camomile flowers be boiled in three pounds of
water down to two. When this is cold, it ought to be strained, and
half a drachm of opium diffused in a pound of the decoction. Of this,
a sufficient quantity is to be added to powdered charcoal, in order to
form a poultice.
In the second division, the fermenting poultice[67] is often of
service; but it must, like all other applications, be continued no
longer than the state which it was intended to remove remains. If
we continue it too long, we do hurt; for, if it be kept on when it
produces continued pain, it induces a state of overaction, similar to
that which it was intended to destroy. Whenever the surface becomes
redder, and the pain less, it may be useful to employ some other
application, such as laudanum, &c.
[67] The fermenting poultice is made by adding a spoonful of yest to
an oatmeal poultice, and placing it before the fire until it begins to
emit air, or rise up in a bubbling way. It is then fit for applying to
the sore.
The same observations apply to the use of the gastric juice. Cloths
dipped in this sometimes make the overacting surface slough off,
and leave the parts below more healthy. The same may be said of the
expressed juice of sorrel.
Lime water sometimes operates in the same way.
Red precipitate, mixed with its weight of powdered opium, and half its
weight of camphor, may be usefully sprinkled over the surface.
A pound of the recent leaves of hemlock, boiled for half an hour in
two pounds of milk, and then expressed, forms an application which
sometimes abates the pain, and renders the action more healthy. The
juice is to be made into a poultice with crumb of bread.
Decoction of the walnut tree leaves, applied by means of pledgets of
linen, or made into a poultice with bran, is occasionally of service.
When, by any of these applications, the morbid state of the ulcer is
removed, it is to be dressed according to the genus into which it is
then converted.
After these remarks, the treatment of this genus of ulcers may be
comprised in the following observations:
First, In the first variety of the first species, or the simple
fungous ulcer, the cure is to be attempted by pressure, and gentle
stimulants, which render the action more natural, and the granulations,
in consequence, more perfect and compact.
Second, In the second variety of this species, we are to employ the
same remedies, as palliatives, or as means which may promote the
exfoliation of the bone. But, if the disease in the bone be more
extensive and tedious, we must cut down through the ulcer, and apply
caustic, or mechanical cures, such as perforation, to the caries.
Third, In the incipient stage of the first variety of the second
species, we must avoid motion, and all other such causes as tend
simply to increase action. When the disease has consisted of one
short paroxysm, which has terminated, we must promote the absorption
of the diseased granulations, and the process of replacing them with
others which are more perfect, which is effected by such remedies as
render the action which forms them more natural. This is best done
by gentle pressure, and sometimes by poultices. If, however, the
paroxysm continue longer, but in a moderate degree, we must use such
applications as tend more directly to change the action, and diminish
the morbid condition; such as camphorated and opiated preparations, and
sometimes the vegetable acids.
Fourth, When this state becomes confirmed and progressive, the action
being violent, we must use remedies nearly similar to those which are
employed in the last case, and which are useful in the cure of the
inflammatio debilis, at the same time that we enjoin rest, and keep
the part as easy as possible. In some instances, the action cannot
be overcome directly by any application, but is rather increased by
them. In this case, we must lay these aside, and use mild and light
applications; such as fine oil, fresh cream, &c.; at the same time that
we avoid the general causes tending to increase action; such as motion,
heat, spirits, &c.
Fifth, When this state occurs in chronic ulcers, we must use such
remedies as tend to remove the dead or dying granulations which
frequently cover the surface, and such as at the same time produce a
more natural action, and restore to the succeeding granulations greater
powers and perfection, and a more healthy mode of acting. Stimulating
applications frequently have this effect; such as the fermenting
poultice, precipitate ointment, &c.; at other times, narcotic
applications; such as cicuta, &c. are useful.
Sixth, In these ulcers, the redness and pain of the skin which
surrounds the ulcer, is to be treated as the inflammatio assuefacta, by
being dusted with the powder which has been already mentioned, or by
similar remedies.
Seventh, In all of these ulcers, where the action is violent, much
benefit will be derived from inducing the general narcotic action to a
considerable extent. Anodynes are therefore to be freely administered,
at the same time that we employ the proper local remedies.
Eighth, Whenever the ulcer becomes more healthy, and the action less
morbid, the strength of the application is to be diminished; and,
when the state of overaction is destroyed, it must be treated as the
indolent ulcer, because the granulations are still feeble. Pressure is
most useful in this case.