Volume 1 / Part 3 — AN INQUIRY INTO THE CAUSE AND CURE OF SORE LEGS.

However trifling these complaints may appear, they compose a large class of the diseases of a numerous body of people. Hitherto, the persons afflicted by them have been too generally abandoned to the care of empirics, either because the disease was considered as beneath the notice of physicians, or because they were unable to cure it. I would rather ascribe it to the latter, than to the former cause, for pride has no natural fellowship with the profession of medicine.

The difficulty of curing sore legs has been confessed by physicians in every country. As far as my observations have extended, I am disposed to ascribe this difficulty to the uniform and indiscriminate mode of treating them, occasioned by the want of a theory which shall explain their proximate cause. I shall attempt in a few pages to deliver one, which, however imperfect, will, I hope, lay a foundation for more successful inquiries upon this subject hereafter.

I shall begin my observations upon this disease, by delivering and supporting the following propositions.

I. Sore legs are induced by general debility. This I infer from the occupations and habits of the persons who are most subject to them. They are day-labourers, and sailors, who are in the habit of lifting great weights; also washer-women, and all other persons, who pass the greatest part of their time upon their feet. The blood-vessels and muscular fibres of the legs are thus overstretched, by which means either a rupture, or such a languid action in the vessels is induced, as that an accidental wound from any cause, even from the scratch of a pin, or the bite of a mosquito, will not easily heal. But labourers, sailors, and washer-women are not the only persons who are afflicted with sore legs. Hard drinkers of every rank and description are likewise subject to them. Where strong drink, labour, and standing long on the feet are united, they more certainly dispose to sore legs, than when they act separately. In China, where the labour which is performed by brutes in other countries, is performed by men, varices on the legs are very common among the labouring people. Perhaps, the reason why the debility is induced in the legs produces varices instead of ulcers in these people, may be owing to their not adding the debilitating stimulus of strong drink to that of excessive labour.

It is not extraordinary that the debility produced by intemperance in drinking ardent spirits, should appear first in the lower extremities. The debility produced by intemperance in the use of wine, makes its first appearance in the form of gout, in the same part of the body. The gout, it is true, discovers itself most frequently in pain only, but there are cases in which it has terminated in ulcers, and even mortification on the legs.

II. Sore legs are connected with a morbid state of the whole system. This I infer,

1. From the causes which induce them, all of which act more or less upon every part of the body.

2. From their following or preceding diseases, which obviously belong to the whole system. Fevers and dysenteries often terminate critically in this disease; and the pulmonary consumption and apoplexy have often been preceded by the suppression of a habitual discharge from a sore leg. The two latter diseases have been ascribed to the translation of a morbific matter to the lungs or brain: but it is more rational to ascribe them to a previous debility in those organs, by which means their vessels were more easily excited into action and effusion by the stimulus of the plethora, induced upon the system in consequence of the confinement of the fluids formerly discharged from the leg in the form of pus. This plethora can do harm only where there is previous debility; for I maintain that the system (when the solids are exactly toned) will always relieve itself of a sudden preternatural accumulation of fluids by means of some natural emunctory. This has been often observed in the menorrhagia, which accompanies plentiful living in women, and in the copious discharges from the bowels and kidneys, which follow a suppression of the perspiration.

3. I infer it, from their appearing almost universally in one disease, which is evidently a disease of the whole system, viz. the scurvy.

4. From their becoming in some cases the outlets of menstrual blood, which is discharged in consequence of a plethora, which affects more or less every part of the female system.

5. I infer it from the symptoms of sore legs, which are in some cases febrile, and affect the pulse in every part of the body with preternatural frequency or force. These symptoms were witnessed, in an eminent degree, in two of the patients who furnished subjects for clinical remarks in the Pennsylvania hospital some years ago.

6. I infer that sore legs are a disease of the whole system, from the manner in which they are sometimes cured by nature and art. They often prove the outlets of many general diseases, and all the remedies which cure them, act more or less upon the whole system.

In all cases of sore legs there is a tonic and atonic state of the whole system. The same state of excessive or weak morbid action takes place in the parts which are affected by the sores. The remedies to cure them, therefore, should be general and local.

In cases where the arterial system is affected by too much tone, the general remedies should be,

I. Blood-letting. Of the efficacy of this remedy in disposing ulcers suddenly to heal, the two clinical patients before-mentioned exhibited remarkable proofs, in the presence of all the students of medicine in the university. The blood drawn was sizy in both cases. I have not the merit of having introduced this remedy into practice in the cure of ulcers. I learned it from Sir John Pringle. I have known it to be used with equal success in a sore breast, attended by pain and inflammation, after all the usual remedies in that disease had been used to no purpose.

II. Gentle purges.

III. Nitre. From fifteen to twenty grains of this medicine should be given three times a-day.

IV. A TEMPERATE DIET, and a total abstinence from fermented and distilled liquors.

V. Cool and PURE AIR.

VI. Rest in a recumbent posture of the body.

The local remedies in this state of the system should be,

I. Cold water. Dr. Rigby has written largely in favour of this remedy when applied to local inflammations. From its good effects in allaying the inflammation which sometimes follows the puncture which is made in the arm in communicating the small-pox, and from the sudden relief it affords in the inflammatory state of the ophthalmia and in the piles, no one can doubt of its efficacy in sore legs, accompanied by inflammation in those vessels, which are the immediate seat of the disease.

II. Soft poultices of bread and milk, or of bread moistened with lead water. Dr. Underwood's method of making a poultice of bread and milk should be preferred in this case. He directs us first to boil the milk, then to powder the bread, and throw it into the milk, and after they have been intimately mixed, by being well stirred and boiled together, they should be poured out and spread upon a rag, and a knife dipped in sweet oil or lard, should be run over them. The solidity and consistence of the poultice is hereby better preserved, than when the oil or lard is mixed with the bread and milk over the fire.

III. When the inflammation subsides, adhesive plasters so applied as to draw the sound edges of the sores together. This remedy has been used with great success by Dr. Physick, in the Pennsylvania hospital, and in his private practice.

IV. Above all, rest, and a horizontal posture of the leg. Too much cannot be said in favour of this remedy in this species of sore legs. Nannoni, the famous Italian surgeon, sums up the cure of sore legs in three words, viz. “Tempo, riposo, e pazienza;” that is, in time, rest, and patience. A friend of mine, who was cured by this surgeon of a sore leg, many years ago, informed me, that he confined him to his bed during the greatest part of the time that he was under his care.

In sore legs, attended by too little general and local action, the following remedies are proper.

I. Bark. It should be used plentifully, but with a constant reference to the state of the system; for the changes in the weather, and other accidental circumstances, often produce such changes in the system, as to render its disuse for a short time frequently necessary.

II. Mercury. This remedy has been supposed to act by altering the fluids, or by discharging a morbid matter from them, in curing sore legs. But this is by no means the case. It appears to act as a universal stimulant; and if it prove most useful when it excites a salivation, it is only because in this way it excites the most general action in the system.

III. Mineral tonics, such as the different preparations of iron, copper, and zinc.

IV. Gentle exercise. Rest, and a recumbent posture of the body, so proper in the tonic, are both hurtful in this species of sore legs. The efficacy of exercise, even of the active kind, in the cure of sore legs, accompanied by deficient action in the vessels, may easily be conceived from its good effects after gun-shot wounds which are mentioned by Dr. Jackson[65]. He tells us, that those British soldiers who had been wounded at the battle of Guilford, in North-Carolina, who were turned out of the military hospitals and followed the army, soonest recovered of their wounds. It was remarkable, that if they delayed only a few days on the road, their wounds grew worse, or ceased to heal.

In the use of the different species of exercise, the same regard should be had to the state of the system, which has been recommended in other diseases.

V. A nutritious and moderately stimulating diet, consisting of milk, saccharine vegetables, animal food, malt liquors, and wine.

Wort has done great service in sore legs. The manner in which I have directed it to be prepared and taken is as follows: To three or four heaped table-spoonsful of the malt, finely powdered and sifted, add two table-spoonsful of brown sugar, and three or four of Madeira, sherry, or Lisbon wine, and a quart of boiling water. After they have stood a few hours, it may be drunken liberally by the patient, stirring it each time before he takes it, so that the whole substance of the malt may be conveyed into the stomach. A little lime-juice may be added, if the patient requires it, to make it more pleasant. The above quantity may be taken once, twice, or three times a-day at the pleasure of the patient, or according to the indication of his disease.

VI. Opium. This remedy is not only useful in easing the pain of a sore leg, but co-operates with other cordial medicines in invigorating the whole system.

The local applications should consist of such substances as are gently escarotic, and which excite an action in the torpid vessels of the affected part. Arsenic, precipitate, and blue vitriol, have all been employed with success for this purpose. Dr. Griffitts informed me, that he has frequently accomplished the same thing in the Dispensary by applications of tartar emetic. They should all be used, if necessary, in succession to each other; for there is often the same idiosyncrasy in a sore leg to certain topical applications, that there is in the stomach to certain aliments. After the use of these remedies, astringents and tonics should be applied, such as an infusion of Peruvian, or white-oak bark; the water in which the smiths extinguish their irons, lime-water, bread dipped in a weak solution of green vitriol (so much commended by Dr. Underwood), compresses wetted with brandy, or ardent spirits of any kind, and, above all, the adhesive plasters formerly mentioned.

Tight bandages are likewise highly proper here. The laced stocking has been much used. It is made of strong coarse linen. Dr. Underwood gives several good reasons for preferring a flannel roller to the linen stocking. It sets easier on the leg, and yields to the swelling of the muscles in walking.

In scorbutic sores on the legs, navy surgeons have spoken in high terms of an application of a mixture of lime-juice and molasses. Mr. Gillespie commends the use of lime or lemon-juice alone, and ascribes many cures to it in the British navy during the late war, after every common application had been used to no purpose[66].

It is of the utmost consequence in the treatment of sore legs, to keep them clean, by frequent dressings and washings. The success of old women is oftener derived from their great attention to cleanliness, in the management of sore legs, than to any specifics they possess which are unknown to physicians.

When sore legs are kept from healing by affections of the bone, the treatment should be such as is recommended by practical writers on surgery.

I shall conclude this inquiry by four observations, which are naturally suggested by what has been delivered upon this disease.

1. If it has been proved that sore legs are connected with a morbid state of the whole system, is it not proper to inquire, whether many other diseases supposed to be local, are not in like manner connected with the whole system; and if sore legs have been cured by general remedies, is it not proper to use them more frequently in local diseases?

2. If there be two states of action in the arteries in sore legs, it becomes us to inquire, whether the same opposite states of action do not take place in many diseases in which they are not suspected. It would be easy to prove, that they exist in several other local diseases.

3. If the efficacy of the remedies for sore legs which have been mentioned, depend upon their being accommodated exactly to the state of the arterial system, and if this system be liable to frequent changes, does it not become us to be more attentive to the state of the pulse in this disease than is commonly supposed to be necessary by physicians?

4. It has been a misfortune in medicine, as well as in other sciences, for men to ascribe effects to one cause, which should be ascribed to many. Hence diseases have been attributed exclusively to morbid affections of the fluids by some, and of the muscles and nerves by others. Unfortunately the morbid states of the arterial system, and the influence of those states upon the brain, the nerves, the muscles, the lymphatics, the glands, the viscera, the alimentary canal, and the skin, as well as the reciprocal influence of the morbid states of each of those parts of the body upon the arteries, and upon each other, have been too much neglected in most of our systems of physic. I consider the pathology of the arterial system as a mine. It was first discovered by Dr. Cullen. The man who attempts to explore it, will probably impoverish himself by his researches; but the men who come after him, will certainly obtain from it a treasure which cannot fail of adding greatly to the riches of medicine.

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