AN ESSAY ON THE MOST EFFICACIOUS MEANS OF TREATING ULCERATED LEGS.
IN WHICH The topical APPLICATIONS in general Use ARE CONSIDERED, AND Some new METHODS for RELIEF proposed; WITH PARTICULAR OBSERVATIONS On the SAFETY of HEALING OLD ULCERS.
LONDON: PRINTED FOR THE AUTHOR, AND SOLD BY W. NICOLL IN ST. PAUL's CHURCH-YARD.
MDCCLXXXIII.
[PRICE ONE SHILLING.]
AN ESSAY On the most efficacious MEANS OF TREATING ULCERATED LEGS.
WHOEVER has been at all conversant in the practice of Surgery, or has attended an Hospital, must have frequently observed the difficulty of healing an ulcer in the leg, which even when the patient is young, and appears of a strong constitution, often for a considerable time baffles the most attentive efforts of the healing art; but when the ulcer is of long standing, and the person a little advanced in life, it too frequently not only eludes every endeavour to effect a perfect cure, but is with difficulty brought to that state, so as to be but slightly painful, and in a small degree inconvenient. It is likewise not unfrequent, if the constitutional fault, which disposes to aggravate and continue this disease, is not properly removed, although the surgeon should be so successful as in appearance to heal the sore, that on resuming usual exercise, in the course of a few weeks, the part becomes daily more painful, the tender covering appears slightly tumified, and soon breaking, a sore again appears, that from its situation is liable to be aggravated by the slightest injury, to which patients of this class, from their necessary avocations, are generally subject: the greater number of these unfortunate sufferers being those, who are necessitated to procure their support by labour or servitude, but who, whatever inconvenience they experience from the ulcer, seldom, till after using for some time different cerates and ointments, and sometimes even irritating dressings, apply for surgical assistance. This assistance often falling short of the wish of the practitioner, and expectation of the patient, has induced me to suggest the few following hints, which have occurred from an opportunity of seeing a large number of these unfortunate cases; sincerely hoping, if thereby only a mite is contributed to the public benefit, by exciting more particular attention to this subject, those gentlemen who are truly eminent in their profession, may favour the public with some more certain and expeditious mode of removing this disease; the treatment of which now remains in so imperfect a state, and gives so dark a shade to the general lines of Surgery
Mr. Bell's very ingenious treatise on the Theory and Management of Ulcers, must be admired by every one who esteems the profession of surgery; but it is to be lamented that he has not
particularly
treated on the management of ulcers in the leg.
.
We will first suppose an ulcer of but small extent, its appearance what is usually termed clean, the edges thin, with little or no callosity, and the surrounding parts but slightly discoloured: the usual dressing in this case, is dry lint, immediately on the sore, and over this a plaister of calaminaris cerate, which extends two fingers breadth every way from the edges of the sore, over this a bandage; on removing this dressing once in the day, the lint shall appear covered with thick white matter, the pain, which was at first but slight, go off; yet the sore frequently heals but very slowly. To what cause are we to assign this slow progress in healing? Is there some constitutional fault, or are the dressings the most proper? If the fault was entirely constitutional, may we suppose the healing would not have thus far advanced? Yet how can such mild applications be improper? Is the conjecture improbable, that the plaister of the size before mentioned, (which is constantly applied) by retaining the perspirable fluid, keeps the cuticular vessels over which it is placed, in too relaxed a state? and if this be the case, would not a compress, wet with vegeto mineral water, or any other mild astringent liquor, applied three or four times a day over the lint, sooner heal the sore, when advanced to this state? It may be urged such sore usually heals by the use of lint and cerate; but the time, often more than a few weeks, necessary to effect this, is certainly too long to subject our patient to an inconvenience, provided any quicker, and equally safe mode can be proposed.
This is the most simple state of ulceration. We now consider an ulcer as in a foul state, with a thick callous margin, a thin irritating dark coloured discharge, and the surrounding parts to a considerable extent inflamed, attended with much pain. The usual mode of treating this kind of ulcer, is to foment the part twice a day with flannel wrung dry from a decoction of wormwood, chamomile flowers, &c. then apply some terebinthinate digestive spread on lint, immediately on the sore, over this a large plainster of yellow basilicon. Sometimes a common bread and milk poultice only is applied, (which should be renewed at least three or four times in twenty-four hours) but which ever of these means are used, the foulness of the sore in a few days is usually much removed, the discharge wears a better appearance, and the naked fibres appear of a more florid colour; yet still the callosity of the edges continues as in its first state, and tho' the pain is less, the surrounding parts wear nearly the same appearance. If the bread and milk poultice has been applied, it is usually discontinued when the state of the sore is thus altered, and either dry lint, or lint spread with some digestive ointment, is applied over the sore once or twice a day, and this covered with a large yellow basilicon plaister. To remove the callosity, a small quantity of strong mercurial ointment, daily rubbed on the hardened edges, is by some much recommended; but as the absorbent vessels in parts thus hardened, may be considered almost impervious, we have no good reason to expect this will effect any considerable alteration. A cataplasm of figs, beat fine with a little honey, spread thick on lint, and applied on the edges of the sore twice a day, so as to cover rather more than the callosity, by its softening quality and action on the contiguous surrounding parts, would probably effect a more speedy removal of the hardness. But if after applying this cataplasm for some days, the edges of the sore appear in nearly the same state, it will be necessary to rub them with lunar caustic either once a day, or every other day, in order to destroy the callosity. It must here be understood that the patient uses every endeavour to enjoy the advantage of entire rest.
This state of ulceration being generally considered as attended with some constitutional fault, while the means to heal the sore are employed, some medicine is usually directed to be taken daily. If there is no reason to suppose the disease connected with the venereal virus, or a scrophulous taint, it is generally called Scorbutic; not as the term is connected with the sea scurvy, but that general appellation used for most kinds of eruption, discolourations of the skin, &c. The medicines usually given for this purpose are Aethiop's mineral, cinnabar of antimony, &c. Aethiop's mineral has, by being long in use, obtained credit with some, as a remedy capable of effecting great changes in the constitution; but when it is considered that sulphur joined with mercury almost entirely destroys its active qualities, little good can be expected from the administration of this medicine. Indeed we may venture to assert, the efficacy desired is seldom if ever obtained. Cinnabar of antimony, as a composition of a similar kind, may be supposed to have no better effect. Nitre is another medicine sometimes administered; this possessing a sedative quality, often powerfully abating inflammation, and acting, in a proper dose, as a diuretic, is doubtless in many cases an excellent remedy. But other qualities seem to be wanted for the cure of this kind of ulcer. Calomel likewise, which is sometimes given in a small dose for three or four nights, and then worked off with a brisk purge, tho' frequently repeated, generally fails of producing the beneficial effect required.
If the constitutional fault now treated of, be a too impoverished and acrimonious state of the fluids, and from hence disposition to relaxation of the muscular fibres, the consequence, we have a most noble and almost certain corroberant in the Peruvian bark; but this is likewise given to remove the constitutional fault, and forward the healing of the ulcer, yet too frequently, not with the wished for effect. May it then be supposed, tho' this invaluable medicine will give tone to the relaxed fibres, the fluids are not brought to that balsamic state necessary for completely healing the sore? Therefore, while we administer the bark, a dose of which should be taken three or four times a day, a more nutritive diet than is usually allowed, appears in a great degree necessary. Half an ounce of isinglass dissolved in a pint of milk, and drank daily in small quantities, would probably afford great benefit to those patients whose circumstances in life have necessitated them to live sparingly, or on food but slightly nutritive. A small glass of mountain, or any other generous wine, allowed three or four times a day, might likewise prove of considerable benefit; or salep
That friend of human kind, and excellent physician, Dr. Percival, in his essays medical and experimental, observes,
"The restorative, mucilaginous, and demulcent qualities of the orchis root [salep] render it of considerable use in various diseases;"
and that
"Salep is said to contain the greatest quantity of vegetable nourishment in the smallest bulk."
given to the quantity of half an ounce daily in a decoction
The manner of preparing this decoction, is as follows: Boil two ounces of dried burdock roots cut small, in four pints of water to three; then add half an ounce of powdered salep, continue the boiling until only a quart of liquor remains, which pour through a fine strainer for use.
of burdock root, a coffee-cup full to be drank frequently as common liquor, appears likely to much assist the other means employed.
From the dressings daily applied, and the alteration induced in the constitution by administering Peruvian bark, and allowing a more nutritive diet, we will suppose the sore is become less, the callous edges nearly removed, the discharge thicker, and the pain much gone off, but still the surrounding parts discoloured; yet altho' we are thus far advanced towards the cure, after some days the sore often will appear to heal no further, and not unfrequently part of the new covering disappear, and the sore become enlarged. Are we to seek a remedy, in this situation of the disease, from internal means? Or are different topical applications likely to alter this state of the ulcer, and induce it to heal? No one will doubt the propriety of continuing, or even encreasing the dose of a medicine, before found serviceable. But are topical applications, generally considered, so useful as there is reason to believe they would sometimes prove, at least are they attended to with that care which in some cases they perhaps deserve? Dry lint on the sore, over this a plaister, is the usual application when the ulcer (however deep) appears clean; but may not the plaister in this case produce the same inconvenience as before alluded to? And may we hope some other application, immediately on the naked fibres, will assist the more speedy healing the ulcer? Slightly touching the sore with the elixir of aloes twice a day, then applying fine dry lint, or lint spread slightly over with a mild cerate, and over this a compress, wet with vegeto mineral water, (which compress may be wetted more frequently, if it grows dry) would probably contribute much to the more speedily effecting this purpose. Or using the lint and compress wet with the vegeto mineral water as above, after sprinkling the sore with a powder composed of three parts saffron, carefully dried and finely powdered, and one part powdered myrrh, or with powdered saffron only, (which I have reason to believe, possesses a vulnerary quality, hitherto but little attended to) might much assist our attaining the desirable end—a sound and compleat cure.
In the state of the ulcer, as at first described, the pain will always make our patient ready to comply with our request, to rest the limb as much as possible; but when the sore is brought to a less painful state, may we consider rest then not so necessary, particularly if the roller, which should be constantly worn, is properly applied from the foot to the knee
The Roller I have used for a long time before reading Mr. Underwood's Treatise upon Ulcers of the Legs, &c. was always made of thin flannel, though not formed in the manner he thus directs:
"The kind of roller is to be considered, which ought to be made of the thinnest Welch flannel, not thicker than coarse linen, which advantages no linen can have; it not only being softer, sitting easier, and making no plaits on the skin, but is elastic to a very considerable degree. This is greatly increased by its being torn across and sewed together selvage ways (the hard selvage thread being first cut off) whereby the roller is made to yield to every motion and varying shape of the limb."
Great merit is certainly due to Mr. Underwood for his valuable communications on the treatment of ulcerated legs, &c. and his candour will doubtless excuse the hope expressed in my conclusion of this subject; a subject which I humbly conceive will still admit of many additions, before perfection be attained in the modes of treatment.
.
If the danger of healing an old ulcer, is urged against our endeavours to generally compleat a cure—if it is remarked that loss of appetite, pain in the stomach and bowels, asthma, and other ill consequences have been observed to follow the entirely suppressing a discharge from the leg, that has been of long continuance; may we suppose (as the process of healing is usually slow) that careful attention to the state of our patient's health, particularly when the discharge is much lessened, will enable us to judge of the safety of perfectly healing the sore, or direct us only to continue our endeavours, until it is brought to such a state as to be but slightly inconvenient. When the healing is far advanced, and after an issue made in the thigh has discharged freely for several days; should our patient frequently find pain in the stomach and bowels, which although relieved by a mild purge, or other proper medicine, soon again returns—should shortness of breath, or particular lassitude be observed on any change of the weather, or increase of exercise—should want of usual appetite follow, or nausea often recur; may we not consider these sufficient indications to desist from the constant use of healing applications, and in their place sometimes apply immediately on the part a little mild digestive ointment spread on lint, in order to continue the discharge and keep the ulcer in such state as to be but in a small degree inconvenient. On the other hand, if as the cure advances no difference is observed in our patient's state of health, but what is rather for the better, may not our endeavours to completely heal the sore be safely pursued? Which if we are so happy to effect, leaving an issue in the thigh, to be carefully attended to for some time, will make us easy respecting any future consequence.
Could we in every case of ulcerated legs, have the happiness to make a safe and perfect cure, what a large portion of human misery would be removed: How many a father on whom a numerous family depends for support, if freed from pain, would earn the bread of comfort! What pleasure would many mothers find in performing the necessary task of care for their, perhaps, yet tender offspring: Or, supposing the parents free from what would be their pride, in beholding their children in the full use of their limbs! If I appear too earnest, the importance of the subject, I hope, will plead in my excuse, this disease too frequently at present, like a sable cloud spreading a gloom over the field, so splendidly enlightened by the many modern improvements in Surgery.
Having considered the means likely to be beneficial to those ulcers in the leg to which the most virtuous are alike liable with those who are regardless of irregularities; as in the latter the
venereal virus
is often found to accompany or produce the ulceration, some attention to this state of the case becomes necessary. If the cause of the disease is confessed we have then certain grounds to proceed on, but (as too often is the case with females) if the cause is concealed, although the appearance of the sore to the person much conversant in practice, and particularly if any copper-coloured spots appear in the other parts of the limb, will give almost a certain information of the nature of the case, yet the delicacy of such a circumstance requires that we proceed with caution.
For the Venereal virus we have the happiness to possess a true specific in mercury, and as the mode of administering this valuable medicine must be supposed to be known to every surgeon, any hint on this point may be considered as superfluous; But with submission to the future consideration of those gentlemen who so strongly assert the efficacy of corrosive sublimate in the advanced stages of the veneral disease, I would beg leave to say, the result of my frequently administering it has rather tended to prove it very uncertain; for although external symptoms will from its use generally soon disappear, and health seem to return, yet after some time the patient will not unfrequently find the disease again appear, without having the least cause to suppose it is renewed.
The use of mercury for this kind of ulceration, appears indispensibly necessary; and if half an ounce of isinglass dissolved in a pint of milk is taken once or twice a day during the course, It may afford great assistance.
The efficient cause by a judicious mercurial course being removed, the ulcer usually changes its state, as in the manner before described; and although the degree of callosity in these cases is usually greater, we have reason to hope a cure may be effected by the use of the same external means. Two or three doses of Peruvian bark likewise, taken daily when the sore is brought to a healing state may much assist the more effectual recovery of health, and prove of great assistance in compleatly healing the ulcer.
Another yet more formidable evil too frequently accompanies or is the cause of ulcers in the leg—a scrophulous taint. This kind of ulceration too generally gives us reason to lament that no
certain
assistance can be found, by whatever means we attempt relief. May we suppose this evil has been more known to late generations? Or may we agree with those who conjecture that the
venereal virus
in the parent can operate to transmit a scrophulous taint to their children's children? what more than single cause have we then to lament "That dreadful malady, the severest scourge with which in this life offended Heaven chastens the indulgence of criminal desire
This is the expression used by that late elegant writer Dr. Robertson, in his history of America.
" ever was transplanted from American soil: for surely, adding this calamity to those which formerly embittered human life, has almost formed a counterbalance to all the benefits Europe can derive from the discovery of the new world.
But let us not too darkly shade the scene— If it too frequently happens that endeavours to cure the Scrophula are unsuccessful, in some cases experience teaches the man of practice, much benefit may be obtained, and we will indulge the hope, that to some future age will be known that
certain
remedy which hitherto has been sought with such ill success.
When an encysted scrophulous tumour is formed in the neck or other part of the body, we have a certain assurance of the nature of the disease; but as ulcers in the leg are often truly scrophulous when no tumour of this kind has appeared, it becomes necessary to enquire what peculiar appearance such sores wear, that we may not suppose those of this class which are in no degree connected with scrophula, or be discouraged in our attempts when we find an ulcer that from
neglect
only is brought to such state that the means successful in other cases, are long before they produce any favourable alteration. The edges of scrophulous ulcers have never that degree of callosity observable in other ulcers; but, on the contrary, appear lax and spongy; the naked fibres have not usually so florid an appearance, and the discharge, even when the sore appears clean, is usually thin and illconditioned: if the sore enlarges, it is more hastily than in other ulcers, and the fungous appearance of the marginal fibres is invariably to be observed; the muscles of the whole limb when the ulcer has been of long continuance likewise appear much relaxed.
That the lymphatic vessels are the immediate seat of scrophula is an opinion now generally received; that debility of the constitution in general, is always connected with this disease, attentive observation will certainly convince us: but much more I fear is necessary to be known before we become able to direct with certainty, our means for relief. It may not however be improper before any thing is said on the external treatment, to pay some attention to the internals usually administered. Aethiop's mineral, and cinnabar of antimony, which some writers much recommend, have been attended to with respect to their use, in those ulcers usually termed scorbutic; burnt spung much recommended by Dr. Mead in this disease, seems to have little better claim to our attention; decection of the woods and medicated lime-water that are frequently serviceable in cutaneous diseases, appear not to possess the efficacy here required; mercurials in scrophulous cases, almost certainly fail of producing any lasting good effect, and the various preparations of antimony in this disease, lose their force; even that lately so very fashionable medicine, extract of hemlock, has perhaps never been found to entirely eradicate this discase, notwithstanding the powers some boast it possesses, even of curing cancers; Poudre unique has not come much within my observation, but admitting a superlative efficacy in this composition, its extravagant price must ever prove a barrier to its general use; for who in the common line of life can afford to give more than the price of gold for
copper,
in whatever curious form it is offered? Those who profess a good will to mankind, certainly miss the aim they intend, if their own interest strongly glares in that light where it should be only just discernable; but it is far from the writer's wish to pass an invidious comment on any one.
If we attend to the efficacy of vegitables, may the conjecture be indulged, that modern practice does not sufficiently pay attention to the advantages to be derived from them. It appears, the field furnished our forefathers with almost the whole of the means they employed in the removal of diseases; some will, perhaps, suppose disease was not to them so formidable as it at present often appears. It certainly is not improbable, that modern luxury states our account more on the debtor side: but allowing this, and that chemistry furnishes more powerful and speedy remedies in many cases, it is more than probable experience would inform us many now neglected herbs possess great efficacy
"The simple herb
plantain,
blunts the venomous bite of the
rattle-snake,
which would otherwise prove mortal."
Black's Historical sketch of Medicine and Surgery.
. Dr. Armstrong in his account of the diseases most incident to children, describing scrophulous tumours in the neck, &c. has a passage which I cannot refrain taking the freedom to transcribe: "For swellings of this kind, when taken in time, that is, before the skin begins to be discoloured, the best application that I have tried, is the juice of the root of swordgrass, or the yellow water-flag,
(gladiolus luteus)
rubbed well in upon the part two or three times a day. A small quantity of this juice recently expressed, and snuffed up the nostrils in a short time after, occasions a great heat in the cavities of the nose, mouth, and throat, and a very plentiful discharge of saliva from the mouth and mucus from the nose, as great of the former as if the patient were in the height of a salivation, which continues sometimes for two or three hours or more; and I have heard of some very obstinate chronical and periodical tooth-achs and head-achs having been removed by this discharge, after a variety of other remedies had been tried in vain. This effect of the juice on the salivary glands when snuffed up the nose, first induced me to try it externally upon scrophulous swellings, and I have had the pleasure of observing it to answer extremely well, even upon some tumours of long standing. It has occurred to me sometimes to try it inwardly as an alterative upon some scrophulous patients, but I have not yet done it. I must not forget to mention, that the larger and older the root is from which the juice is expressed, and the deeper its colour, the stronger and more efficacious is the medicine." My use of this remedy to scrophulous tumours has not been equally fortunate with what the Doctor relates, but I must be free to own, the tumours to which it was applied, had been of very long standing.
What effect the application of vervain root in the manner directed by Mr. Morley would produce in this species of ulcer, I cannot attempt to say; supposing myself not to possess the portion of faith necessary for those who make the application, as well as those to whom it is applied; yet I feel conviction of the goodness of Mr. Morley's heart, and the sincerity of his intention in favouring the world with his publication on scrophulous complaints.
From this digression, the subject treated on cannot, perhaps, be better resumed than by observing the virtue of Peruvian bark when joined with soluble tartar; the dose —two scruples or half a dram of each, given three or four times a day; this medicine regularly taken for some weeks, together with the use of the burdock decoction with salep, would probably be found to produce much benefit in the general appearance of this disease, as well as the kind of ulcer now treated on.
The common dressing—dry lint on the sore, and this covered with a large plaister of basilicon or some mild cerate, is generally the whole external means employed, when the sore, whatever be its extent, appears clean. But may the claim before urged for topical applications be again applied here? The relaxed appearance of the sore must certainly bespeak all applications of the emollient class improper, and direct our attention to those possessed of a different quality. Elixir of aloes applied on the sore twice every day, as before mentioned, and this covered with a compress wet with mindererus's spirit, in two ounces of which is dissolved two drams of crude sal armoniac, would probably prove very useful; or camphire powdered very fine and slightly sprinkled over the whole sore twice a day, over this some fine lint, and the whole covered with a compress wet with vegeto mineral water, might still more assist the healing of the sore. I have had the satisfaction to observe a sore in the leg that almost daily enlarged, where the fibres appeared pale and much relaxed, and the discharge was thin, sharp and irritating, by the use of camphire in this manner, soon wear a more favourable appearance, the fibres soon became of a more florid colour, the discharge by degrees become thicker, the sore daily mended, and with the assistance of bark, &c. internally, became perfectly well.
The wide field of medicine, I am well aware, affords ample room for proposing many more useful hints than come within my observation on this subject; nor have I attempted to describe ulceration in all its different appearances. The hope of inducing some more able hand to favour the world with a more certain mode of treating ulcers in the leg than what at present has come in general use, being what principally disposed me to attempt this short essay, if by its publication the smallest portion of information be contributed, my endeavours will be abundantly repaid.
FINIS.