DISSERTATION II. CONTINUED. (continued 2)

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.

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 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.

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 perfect58; 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 action59. 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.

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 below60, 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.

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 mercurielle61 as will make it moderately pungent, may be usefully applied before the dressing.

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 ulcer62, 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.

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. Hepatizatæ63 guttas decem. Aq. Font. uncias octo.

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 good64.

All the applications ought to be made gently, and lightly; because any mechanical irritation increases the disease.

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 service65.

A poultice, formed of decoction of camomile flowers, opium, and charcoal66, is frequently of use, and should be employed when the laudanum and camphorated spirit fail. This should be applied cold.

In the second division, the fermenting poultice67 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.

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.

GENUS IV.

Of the Inflammatory Ulcer.

It sometimes happens, that the ulcerative action becomes converted into the inflammatory; the discharge diminishes, and sometimes ceases; the surface is red; and the edges and surrounding skin are elevated and inflamed. This, which has been called the phlogosis ulceris68, strictly speaking, does not belong to the division of ulcers, because the ulcerative action is destroyed; but, as it is preceded, and very quickly followed by this action, and as the solution of continuity, and other external appearances continue, this affection may be allowed to rank as a genus amongst ulcers, in conformity to common language.

When the pain and inflammation are considerable, leeches are frequently applied with utility in the vicinity of the sore; but it is more generally useful to apply warm poultices, which restore the secretory state, and the ulcerative action.

GENUS V.

Of the Suppurating Ulcer.

This genus, like the last, accurately speaking, does not belong to the class of ulcers; but, as it is so intimately connected with it, both in its causes, and treatment, and appearances, it is of some practical utility to admit the arrangement.

When an abscess is opened before the ulcerative action is induced, we have an open suppurating sore; but this is not the sore which is meant to be described here.

The suppurating ulcer is, when simple, and independent of any specific action, most frequently only a high degree of the overacting ulcer; but, as its symptoms are somewhat different, and as it nearly resembles some specific sores, differing from these only in the absence of the peculiar action, resulting from the application of a poison, it may be proper to consider this as a separate genus.

When the ulcerative action is very imperfectly carried on, which often arises from overaction, we find, that the organic particles are thrown out, not in the form of granulations, but in a more inorganic state, and lie upon the surface, mixed with the discharge from the other set of vessels. This has the appearance of very thick tough pus, and the sore which yields it may properly be considered to be in a suppurating state. This ulcer is distinguished by the pain which attends it, by a redness which surrounds the margin, and a hardened base, whilst the cavity of the ulcer is filled up with a thick straw-coloured substance, somewhat like lymph, which adheres firmly to the surface. This is improperly called a slough.

This appearance and condition may be excited in a simple ulcer, without any apparent application of contagion; but it is still more frequently the consequence of some morbid matter acting on the part, and producing specific ulceration, which will be afterwards considered. I may only here observe, that it has, in some of these cases, been considered as a species of gangrene, as, for instance, in the cynanche maligna; but, whatever may take place in the advanced stages of this disease, there is at first no gangrene, but a suppurating ulcer, which throws out imperfect granulations, or rather a morbid purulent discharge (for the one runs naturally into the other), which forms what is called a slough.

The treatment of this ulcer consists first in procuring a separation of the tenacious covering, by such remedies as shall, at the same time that they do this, make the action more healthy.

A pretty strong solution of the argentum nitratum, or l’eau mercurielle, diluted with equal parts of distilled water, applied by means of a brush, frequently produce the desired effect.

The acetous infusion of Cayenne pepper, applied in the same way, is likewise useful.

Poultices made of decoction of camomile flowers, and equal parts of charcoal and barley meal, are sometimes of service in removing the matter, and rendering the action more truly ulcerative.

Opiates ought to be freely administered.

When this state of the sore is removed, the ulcer must be treated according to the condition of the ulcerative action. Most frequently it belongs first to the overacting genus, and must be treated accordingly, and then to the genus of indolent ulcers, in which case, pressure is to be employed as a termination to the cure.

When an overacting ulcer has, without the assistance of local applications, ceased to overact, it not unfrequently suppurates; that is to say, no granulations are formed, but the two sets of vessels throw out an inorganic matter, and the surface of the sore has a lymphatic appearance.

The best dressing for this state is dry lint, with a pledget spread with cerate laid over it.

Of the Effects of the Ulcerative Action on the Constitution.

The condition and qualities of an ulcer, do not, in every instance, depend upon causes which are entirely local, but frequently are connected with some general state, or mode of action, of the system. General weakness must, for example, influence the performance of any action in a particular part; and, therefore, an ulcer in those who are infirm, and exhausted, cannot readily perform the necessary healthy action, or proceed quickly toward a cure; nor is it easy, in these circumstances, by any local applications, to communicate the necessary action, and the correspondent power, which shall enable the part to heal. In the same way, there are some people so irritable, that an ulcer shall very readily assume the overacting state, which can only be removed by such remedies as act on the general system. Besides those which may be considered as simple conditions, there are many other actions, which are peculiar and unnatural, which influence the ulcer, or in which ulcers often appear as symptoms. These ulcers are specific, and must be afterwards considered.

As the state of the system has a considerable influence on the condition of an ulcer, so also has the state of the ulcerative action an effect on the constitution. A healthy ulcer, unless very extensive, has little effect on the system; but, unhealthy ulcers, or those which are very large, although the action may be sufficiently perfect, produce a greater or less degree of the general diseased formative action, or what is called hectic.

From the principles which have already been laid down, it may easily be understood how an unhealthy ulcer should induce hectic. When considering the doctrine of suppuration, the effects of this on the constitution, or the production of a general diseased formative action were attended to. It was also mentioned, when considering ulceration, that the ulcerative action had a tendency to produce similar effects; and this it does, with a certainty proportioned, cæteris paribus, to the unhealthy condition of the action, or its approximation to the suppurative action; for the less perfect that the ulcerative action is, the more nearly does it resemble the suppurative one.

Healthy ulcers, if very extensive, produce likewise considerable effects on the constitution. This is chiefly perhaps owing to the purulent action, which makes a part of the ulcerative one; for this morbid local secretory action induces a general change, in the same way as other acute changes, of either the formative action itself, or any other intimately connected with it, such as the interstitial. But, besides this cause, the granulating action, although healthy, co-operates with the diseased interstitial action, or the purulent part of the ulcerative action; because, although the granulations, or organic particles, be healthy, yet they are formed in an unnatural situation, and with greater rapidity, and in greater numbers, in a given time, than naturally they ought to be; and, therefore, the action of the part requires greater power for its continuance than is possessed. There is consequently, then, weakness produced, which, by association, affects the system, and co-operates with the diseased formative action, increasing the general disease. The consequence of this state, likewise, is, that the ulcer comes, after some time, to be rendered unhealthy, owing to the deficiency of power to support the necessary action; in which case, the granulating action comes to be also diseased, and co-operates still more with the former morbid condition of the interstitial vessels, or the purulent action, which, although a part of a healthy ulcerative action, is yet itself a morbid secretion, and an unnatural action.

The effects of the ulcerative action on the constitution, are to be alleviated by good diet, free air, and the other remedies which have been pointed out when formerly considering hectic, to which I now refer. I shall only observe, that some of these remedies are employed occasionally with little judgment, and when they are not indicated. It is, for instance, a common practice with some, to prescribe the bark for the cure of every ulcer, whether the constitution be affected or not. But, from many trials, I am confident that it is of very little service, unless when a general disease, whether it be called weakness or hectic, exists.

When the proper remedies for the cure of hectic, conjoined with necessary local applications, fail, the diseased part must be removed; but, before doing so, it is, in every instance, proper to form a pea issue, in order still to keep up a secretory action, the good effects of which have been already noticed.

The restlessness, and febrile symptoms, which are sometimes produced by painful sores, are best relieved by anodynes.

Of the Cure of the Inflammatio Debilis, and the Treatment of Mortification.

The causes and nature of mortification having been already explained, I shall now consider the means of prevention, and the method of cure. The remedies necessary for procuring the resolution, or suppuration of the inflammatio valida, having been formerly enumerated, it will be unnecessary here to make any repetition, or to say more than that we are to prevent mortification by endeavouring to induce one or other of the other terminations, and that the remedies which do so are to be employed with a promptitude and assiduity proportioned to the greatness of the action compared to the powers of the part; and, therefore, that in the intestines, &c. we must pursue our course speedily, if we expect to prevent gangrene.

Mortification, however, is still more apt to succeed the inflammatio debilis, or inflammation of weakened parts; and, therefore, the treatment of this will now more naturally come to be considered, as forming a part of the prophylaxis of mortification, than in any other place.

The most frequent instance which we have of the inflammatio debilis, is the inflammation of parts which have been previously benumbed with cold; but it may also be produced by the action of any of the common exciting causes of inflammation, in weak and reduced habits, or by bruises in sound parts, &c.

When a part has been exposed to much cold, it may inflame, from two causes: First, the communication of action; secondly, the application of subsequent stimulants, more especially heat. Both of these tend to excite an action in the part, which is greater than its power would naturally perform, and, therefore, it becomes diseased, or inflammation is produced, and the little energy which did remain is soon destroyed. The operation of the first cause is prevented by lessening the action of the surrounding parts, by the application of moderate cold, whilst we avoid motion, and whatever may tend to act directly on the part, and co-operate with this cause. The operation of the second cause is prevented by keeping away every agent which will tend to excite action, or at least those which tend to do so suddenly. In the generality of cases, it is perhaps most proper at first to do nothing; because, whatever we apply, tends to excite a greater action than can be sustained; we ought, therefore, to delay any remedy until the part has begun to recover itself, and the action and corresponding power has begun naturally to increase; we may then interfere, by applying such remedies as increase the action, which are perhaps now more useful, by preserving the ground which is gained, than by increasing still farther the action. Of this kind is heat, which must, upon this principle, be applied with great caution, and must, in its degree, be nicely adjusted to the existing state of action. When a part, then, is benumbed with cold, we ought at first to apply a degree of heat, very little above that which the parts were formerly exposed to, which, in one sense, may be said to be doing nothing; for this step is intended merely to prevent farther injury. When this is continued for a short time, we may suppose that the part has begun to act a little more in a natural way, which is attended, as was formerly explained69, with a correspondent increase of injury. We then increase the heat, but very slowly, and taking a long time to bring the part near its natural temperature, being regulated by the progress which the part itself is making; for the application of heat may be considered in two points of view, in this case; first, as the removal of the injuring cause; and, secondly, as a stimulus to action. If, then, the part do not recover itself, in proportion to the removal of the hurtful cause, but remain stationary, it is evident that a farther removal is at present useless, and the stimulus which is consequently given is highly dangerous. By these means, then, we proceed slowly toward recovery, and keep up the ground which we have gained.

If, however, the action of the part have been sunk very low, then recovery is impossible, there being little or no energy, and so little action, that it cannot increase itself toward the natural state. In this case, our endeavours must fail, and will even kill the part sooner than if we had let it alone; for the least increase of action destroys the life of the part, which may, in this case, be compared to a dying taper, which gives one brighter flash before it becomes for ever extinguished.

If, on the other hand, the action have not originally been sunk so low as to make the process toward death continue progressively, but the remedies have been applied too quickly, or, from any cause, have failed to produce this effect, then the action becomes inflammatory. The pain becomes of a burning kind, there is a feeling of pulsation, and the part becomes redder, or livid, whereas, before, it was bluish; from the stagnation of the blood, there was no feeling of pulsation, or arterial motion, and the sensation was that of a painful cold and weight. The inflammatio debilis is now induced, and the danger is great, but still there is a possibility of recovery, which is exactly in proportion to the degree of previous diminution of action, and to the rapidity with which the subsequent inflammatory action was induced, and the degree to which it is raised; or, in other words, the danger is proportioned to the disparity betwixt the action and the power.

The remedies for this disease are such as tend to induce an action similar to the natural one, by which we remove the diseased one; for we know of none which excite the natural action directly, otherwise they would be of universal utility, and would, in the present instance, be preferred to every other. The remedies which we employ with this intention, are bark, opium, &c. internally, and vinous, or spiritous applications externally. These, however, would be pernicious, were there no inflammation present, because they would, by exciting action, tend to induce this; but, when, the inflammatory action is once induced, then, as they excite one more nearly resembling the natural one, they are useful; for, on the one hand, they destroy the morbid one, and, on the other, increase the power of recovery; but, for this purpose, internal medicines, and good diet, must be given, as a source whence the energy is to be renewed, by the renewal of the natural action. Heat is of the most pernicious tendency in this complaint; because it simply increases the exciting action, and, therefore, makes the inflammatory action still more violent. The applications, therefore, ought to be cold, as long as the morbid action continues; but, when it is abating, and recovery is going forward, they may be made a little warmer, as they will thus accelerate the healing process which is taking place; but this requires much prudence.

Spirit of wine is one of the best applications in this disease, and is one very generally employed. Camphor is frequently added to it, and appears to increase its efficacy. Pledgets dipped in camphorated spirit of wine, and applied to the part, will, if frequently renewed, in many cases, remove the inflammation, and prevent gangrene; but, in every instance, it at least relieves the pain, which uniformly returns, if, when the inflammation is violent, we omit the application, or use a weaker spirit, such as the proof spirit.

Essential oils, particularly that of turpentine, which is easiest procured, are also useful, but are inferior to the alcohol.

Laudanum, in slight cases, is useful as a topical application; but, if the inflammation be more severe, it must be mixed with rectified spirit. A very useful application may be prepared by adding two ounces of laudanum to a pound of the spt. vin. camph. of the pharmacopœia.

Internally, the bark must be exhibited in full doses, with such a quantity of wine as the feebleness of the pulse points out; but we must be prudent in this respect, because, if we give too much, we may increase the local disease. As long as it does not increase the pain, or quicken the pulse, it is to be considered as useful.

Opiates are extremely necessary in the inflammatio debilis, and, in general, require to be given freely.

Soups, and other articles of nourishing diet, are absolutely requisite, and ought to be given in small quantities at a time, but frequently repeated.

By these means, we may frequently resolve the inflammation completely; but, at other times, when we have gained a certain ground, the inflammation terminates in the suppurative action; or, in other words, when the parts have gained more strength, and the action has come more nearly to resemble the inflammatio valida, which has continued for some time, a similar termination takes place. This event cannot, perhaps, in these cases, be prevented, and, although it may occasionally protract the cure, yet it diminishes the danger, making mortification less to be dreaded. The best treatment, in these cases, perhaps, is to continue our usual applications, avoiding warm poultices until the action be fully formed; then moderate heat may accelerate the progress of the abscess toward the surface. The same internal medicines must be exhibited, the anodynes, however, being gradually diminished as the pain (which marks the necessity for their use) abates.

It too frequently, however, happens, that either our remedies fail, or the proper ones are not assiduously and judiciously employed, in which case mortification takes place. This requires the same treatment, in whatever way it is induced, only its progress is, from certain causes, more rapid70 in one case than in another, and, therefore, requires the more free use of the appropriate remedies; but the general principle is, in every case, the same, and, therefore, I shall here consider the disease indiscriminately, whether it succeeds the inflammatio valida, or debilis; because, in both instances, the case is exactly the same, only, in the first, the weakness which induces mortification, is produced by the inflammation alone, whereas, in the second, it existed to a great degree before the inflammation was excited.

Mortification is to be prevented from succeeding the inflammatio valida, by timely bleeding, and the use of the agentes dissimiles, by which we procure resolution, or at least make the induction of the purulent action more easy. In the inflammatio debilis, it is to be prevented by remedies of an opposite nature.

When, however, these remedies fail, and mortification does take place, our great object must be to prevent it from extending far, and from injuring the system. These intentions are answered by the same remedies which cure the inflammatio debilis; because the local treatment of mortification is merely that of the inflammatio debilis; for it is only the parts which are still alive, or inflamed, which can be acted on by our remedies.

The remedies are either general or topical, and may be considered under these divisions; but both must be used at the same time.

Many of the older writers, proceeding upon the humoural theories, began their treatment of gangrene by bleeding and purging, after which they prescribed theriaca, and other stimulating applications. Some modern authors still adhere, in part, to this practice, and consider the loss of blood to be advantageous in cases of incipient gangrene. Mr. Bell, who is one of the latest writers on this subject, informs us, that, when the “general symptoms of inflammation, particularly a quick, full, or hard pulse, still continue violent, and especially when the patient is young and plethoric, it then becomes absolutely necessary, even although mortification may have commenced, to empty the vessels a little by one general blood-letting,” which, “in such cases, may in reality be considered as an antiseptic; and it does often indeed, in this particular situation of mortification, prove more powerfully so, than all the different articles in general enumerated as such.” If, however, we consider the nature of mortification, and the circumstances under which it is most likely to occur, we must look upon this practice as dangerous, and must be permitted to doubt whether the full hard pulse is to be met with after the commencement of inflammation, or whether the symptoms of the inflammatio valida, (in which alone bleeding is admissible) still continue violent, after one portion of the inflamed part is evidently gangrenous. Is it reasonable to suppose that one portion of the inflamed part shall be already dead, or dying, and that yet the rest shall not have begun to suffer? or that the action shall not have become converted into the inflammatio debilis, (if it were not originally this)? This surely is not the time for bleeding, purging, and debilitating remedies; but the part must be considered as possessing the low inflammatory action, and the patient as requiring suitable remedies. It may indeed be said by some, in favour of bleeding, that the bark, in some instances, does not check the progress of the disease; but it surely does not thence follow, that it does positive injury, and that remedies of an opposite nature are useful.

The Peruvian bark is, in many cases, one of the most useful internal remedies. It was originally introduced into medicine, about one hundred and fifty years ago, as a cure for intermittent fever; and its utility in gangrene is said to have been discovered by its curing this disease in a person who had it combined with ague, and who was taking the bark on account of the latter complaint. For many years after it was known in Europe, great prejudices prevailed amongst physicians against its use, partly on account of its having been improperly administered, but still more because it was so unfortunate as to cure diseases without necessarily either sweating or purging the patient, a fact which could be only ill explained, or rather scarcely allowed to be possible, by the prevailing theories of physic. Accordingly, although the cases in which it had been successful were by no means a secret, and although severals had the courage to employ it, in spite of all speculative arguments, yet neither Dr. Boerrhave, nor his commentator, Van Swieten, thought it expedient either to recommend or prescribe it. Renewing the motion of the stagnating blood by venesection, and the exhibition of trifling remedies, which could scarcely be called cordial, although sometimes dignified with that epithet, together with the external application of ardent spirits, or oil of turpentine, constituted the current practice in gangrene. These prejudices against the bark, which originated in ignorance, and were supported by attention to a foolish theory, continued long; but the want of a better remedy began at last to make them gradually give way, and the success of empyrics who used the bark soon completed their downfal.

The bark induces an action nearly similar to the natural one, which is greatly injured, and, therefore, it gives a check to the progress of the disease; but, if its operation be not assisted by nourishment, &c. its good effects soon subside, because the materials whence new energy can be drawn are withheld, and, therefore, the system cannot profit so much by the establishment of the new action, and by the restoration of the power of converting the vital principle of foreign matter into nervous energy. The bark, then, is of service in two points of view: First, it changes directly the action of the system, it induces, in a considerable degree, an action somewhat similar to the natural action, and, therefore, counteracts the general action of descent which was taking place. Secondly, by inducing this action, it, to a certain degree, produces the same effects for a time which would have been produced by the natural action itself, or increases the power of renewing vitality; for, in the preliminary dissertation, it was mentioned, that the production of energy was exactly proportioned to the perfection and healthiness of the existing action. The good effects of bark, then, cannot be obtained without nourishment and free air.

It uniformly happens, however, that, in many instances, where the action of the bark would be most beneficial, it is impossible to induce it, owing to several causes, but particularly to its effect on the stomach; for, in many instances, it produces sickness, or nausea, in which case it can do no good, and ought to be abandoned. Momentary sickness, after taking a dose of bark, is indeed a very general effect, and does not materially injure its operation; but, whenever it is either frequently vomited, or produces a sickness of considerable duration, it must either be given in smaller quantities, or in a different form, or at longer intervals; or if all of these fail, it must be laid aside completely, because it not only cannot produce its specific effect, but will even injure the remaining powers by its effect upon the stomach.

The best form in which bark can be prescribed is that of powder, which is more effectual than any tincture, or the extracts. This ought to be exhibited in as great quantity as the stomach will bear, which cannot be reduced to any certain scale. In general, an adult ought, if possible, to take half a drachm, or two scruples, every forty minutes, in the most palatable vehicle; for much depends upon the taste, owing to the sympathy betwixt the mouth and the stomach; and, for this reason, the same vehicle ought seldom to be used more than twice in immediate succession; because, by changing the vehicle, we not only change the taste, which has a tendency to prevent loathing, but also modify the immediate action on the stomach, changing, to a certain degree, the former impression, which was perhaps beginning to produce sickness. Lemon juice and water, the different kinds of wines, punch, pimento, cinnamon, and peppermint waters, milk, rose water, beer, &c. afford us a variation which may be usefully employed.

The tincture and watery infusion of the bark, either separately or mixed together, are frequently employed, when the powder is vomited; but, as they must be given in very considerable quantities, in order to produce any good effect, they are very apt to produce sickness, and are likewise so inferior in power to the powder, that they are very little to be trusted.

The extract with resin, is a better form than the tincture, or infusion; and, where the powder is rejected, may be made into pills.

When the stomach rejects every form and preparation, it has been proposed to give the bark in clysters, and this ought certainly to be done rather than lose the effects of the remedy; but, given in this way, its effects are more uncertain. From two drachms to half an ounce of the powder of bark, may be diffused in three ounces of soup, or mucilage, with fifteen or twenty drops of laudanum, and given as an enema. This must be repeated at least every hour and a half, or two hours, until the stomach can retain the medicine.

The wine is very usefully conjoined with the bark, and is even of considerable use by itself, when the bark is rejected. Its operation is more speedy than that of the bark, but it is perhaps more fugacious. The quantity which is necessary to be given depends upon the effect of the local disease upon the system, and on the inability to bear other remedies. A table spoonful may be given in general every quarter of an hour, unless it increase the pain, and frequency of pulse, and produce restlessness, and heat of the skin. In these circumstances, we may be certain that we have increased the quantity beyond the necessity71.

Opium is likewise an useful remedy in this disease, and ought never to be omitted; because it not only diminishes the irritability, and, consequently, the pain, but likewise, like the wine and the bark, counteracts, by the induction of its peculiar action, the progress of the inflammatio debilis, and, consequently, tends to check the mortification. This medicine is most usefully exhibited in full doses, which not only procure ease, but also frequently make the stomach more readily bear other remedies. One grain of the extract, or twenty-five drops of the tincture, may be given at once, and the dose repeated whenever the action of the former subsides. After some time, each dose must be increased one half, and presently doubled, in order to produce the same effect as it did at first.

These remedies may give a temporary check to the disease; but, unless nourishment be conjoined, in every possible form, they will not of themselves be able to effect a cure, if the disease be tedious. Soups, jellies, milk, sago, &c. must be assiduously given in small quantities, and even thrown up as clysters, if the stomach cannot bear them.

Vegetable acids, fixed air, wort, &c. have been recommended in this disease, probably upon the supposition of the existence of a putrescent matter, or from their utility in scurvy. Wort, however, and fixed air, do not appear to be of very great benefit in this disease, at least they are by no means to be put in competition with other remedies of more approved efficacy, or allowed to interfere with their exhibition. The acid of lemons seems to be more generally useful than the carbonic acid; and, perhaps, the nitrous acid would be equally useful with the citric acid. These acids do not operate by counteracting putrefaction, but by counteracting the action of descent, inducing a more healthy action, and tending to excite ulceration, which is the mean employed for separating the dead part, and producing restoration. For this purpose, however, the acids must be given freely, otherwise no good is done.

The local treatment is to be conducted on the same principle as in the cure of the inflammatio debilis. Pledgets, dipped in the oil of turpentine, tincture of myrrh, or rather in camphorated spirit of wine, which is one of the best applications which can be used, ought to be made use of.

These remedies can do little service when applied to the dead portion; but, as the whole part does not die at once, there are always some portions which are still in the inflamed state, and on which they act. They likewise prevent the progress of the disease, by operating on the skin which is contiguous to the gangrene. Every mortification, in general, attacks the skin first; or, in other words, the inflammatio debilis spreads faster along the skin than along the deeper parts; but, when once the skin is inflamed, and mortifies, the disease extends to a greater or less depth below the surface. Whatever, then, operates on the surface, and prevents the progress of the inflammation, or cures the part which is already inflamed, will tend to check the extension of the disease, especially if the proper internal remedies be made use of with a view to prevent the extension of the action of descent.

Formerly, in order to allow these remedies to come in contact with the living parts, it was customary to make incisions through the dead portion, and not unfrequently through part of the living substance. But, as these cannot prevent the extension of the disease over a greater surface, and, as the irritation which is given, and the exposure of parts which have not yet assumed the ulcerative action, tend to increase the inflammatio debilis, the practice must be considered as improper72. It is now indeed almost universally laid aside, owing, in a great measure, to the observations of the ingenious Mr. Pott.

Antiseptics, such as decoction of camomile flowers, &c. have been recommended as external applications; but, whatever effects they may have on the matter which is already dead, it is evident that they can be of no service in preserving the living parts from suffering death. All that can be expected from them is to check the putrefaction of the dead substance, which they have very little power to do; and, therefore, they can never come into competition with more valuable remedies, such as the camphorated spirit of wine, &c.

When, by the use of the remedies already mentioned, the progress of the gangrene is stopped, the ulcerative action is induced in the part immediately adjoining to the dead portion, and a red line of separation appears. By means of this ulcerative action, which takes place in every point where the mortification stops, the dead part is separated from the living, and comes away as soon as the bonds of dead muscular fibres, tendons, &c. which unite them, are destroyed by putrefaction. When this separation takes place, or when it is advanced so far as to permit us to accelerate it by dividing the loose tendons, &c. the exposed part must be dressed as an ulcer, or wrapped up in a poultice of the same temperature with the human body.

If, however, the disease have penetrated deep, and destroyed the limb so much as to render it impossible to cure it, or useless, if it were possible, then amputation must be performed; but this, whatever desire the patient may express, must not be practised until the mortification be fully stopped, and the ulcerative action induced; because, if performed sooner, the mortification seizes the stump, and the patient is quickly killed. The system is likewise in such a state as to be unable to sustain the action which is necessarily produced by the operation. It is even improper to cut too near the diseased portion; because the parts here, although the mortification be stopped, are so weakened, that they are less apt to unite. The vessels often break out soon after they are tied, and a new mortification is by no means an unlikely occurrence. Even when the amputation is performed pretty far up the limb, the corners of the stump frequently mortify, or become livid; but a few doses of bark and wine stop the progress of the disease.

Although it is a general rule that amputation is necessary whenever the member is so destroyed as to become useless, and although this must not be performed until the ulcerative action be induced, yet it must not invariably be performed whenever this action takes place, because sometimes at this period the patient is unable to sustain the general action which the operation would produce. We must, therefore, if the patient be much reduced by the extent, or long continuance of the disease, rather delay until, by good diet, wine, &c. we have procured an increase of strength; but, if we find that either the patient loses ground, or his weakness remains stationary under this treatment, we must then amputate; because, it is probable, that the continuance of the dead portion in contact with the living is tending to induce still the general action of descent73.

When we do not deem it adviseable to amputate very soon after the induction of the ulcerative action, it is sometimes useful to cut off part of the black mortified portion, or perhaps to remove a joint, by cutting through the remaining ligaments. In this way, we lessen the fœtor, and make the patient more comfortable.

After making these observations on mortification, I shall conclude with the following case: