AN ESSAY On the moſt efficacious MEANS OF TREATING ULCERATED LEGS.

WHOEVER has been at all converſant in the practice of Surgery, or has at⯑tended an Hoſpital, muſt have frequently ob⯑ſerved 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 ef⯑forts of the healing art; but when the ulcer is of long ſtanding, and the perſon a little ad⯑vanced 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 un⯑frequent, if the conſtitutional fault, which [4]diſpoſes to aggravate and continue this diſ⯑eaſe, is not properly removed, although the ſur⯑geon ſhould be ſo ſucceſsful as in appearance to heal the ſore, that on reſuming uſual ex⯑erciſe, in the courſe of a few weeks, the part becomes daily more painful, the tender co⯑vering 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 un⯑fortunate ſufferers being thoſe, who are ne⯑ceſſitated 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 [5]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 cer⯑tain 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^*.

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, [6]which extends two fingers breadth every way from the edges of the ſore, over this a ban⯑dage; 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 con⯑ſtitutional, 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, [7]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 incon⯑venience, provided any quicker, and equally ſafe mode can be propoſed.

This is the moſt ſimple ſtate of ulcera⯑tion. 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 flan⯑nel wrung dry from a decoction of worm⯑wood, 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 com⯑mon bread and milk poultice only is applied, (which ſhould be renewed at leaſt three or [8]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 re⯑moved, the diſcharge wears a better appear⯑ance, 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 baſi⯑licon 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 ab⯑ſorbent veſſels in parts thus hardened, may be conſidered almoſt impervious, we have no good reaſon to expect this will effect any [9]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 ac⯑tion 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 ne⯑ceſſary to rub them with lunar cauſtic either once a day, or every other day, in order to deſtroy the calloſity. It muſt here be un⯑derſtood that the patient uſes every endeavour to enjoy the advantage of entire reſt.

This ſtate of ulceration being generally con⯑ſidered as attended with ſome conſtitutional fault, while the means to heal the ſore are em⯑ployed, 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 [10]Scorbutic; not as the term is connected with the ſea ſcurvy, but that general ap⯑pellation uſed for moſt kinds of eruption, diſcolourations of the ſkin, &c. The me⯑dicines 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 re⯑medy capable of effecting great changes in the conſtitution; but when it is conſidered that ſulphur joined with mercury almoſt en⯑tirely 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 com⯑poſition of a ſimilar kind, may be ſuppoſed to have no better effect. Nitre is another me⯑dicine ſometimes adminiſtered; this poſſeſſ⯑ing a ſedative quality, often powerfully abating inflammation, and acting, in a proper doſe, as a diuretic, is doubtleſs in [11]many caſes an excellent remedy. But other qualities ſeem to be wanted for the cure of this kind of ulcer. Calomel like⯑wiſe, which is ſometimes given in a ſmall doſe for three or four nights, and then worked off with a briſk purge, tho' fre⯑quently repeated, generally fails of produc⯑ing 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 con⯑ſequence, we have a moſt noble and almoſt certain corroberant in the Peruvian bark; but this is likewiſe given to remove the con⯑ſtitutional 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 ad⯑miniſter [12]the bark, a doſe of which ſhould be taken three or four times a day, a more nu⯑tritive 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 con⯑ſiderable benefit; or ſalep^* given to the quan⯑tity of half an ounce daily in a decoction^‡ of [13]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 ad⯑miniſtering Peruvian bark, and allowing a more nutritive diet, we will ſuppoſe the ſore is become leſs, the callous edges nearly re⯑moved, 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 cover⯑ing diſappear, and the ſore become enlarged. Are we to ſeek a remedy, in this ſituation of the diſeaſe, from internal means? Or are dif⯑ferent 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, [14]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 ap⯑plication when the ulcer (however deep) ap⯑pears 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 [15]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 attend⯑ed 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^*.

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 bow⯑els, aſthma, and other ill conſequences have been obſerved to follow the entirely ſup⯑preſſing 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 diſ⯑charge is much leſſened, will enable us to judge of the ſafety of perfectly healing the ſore, or direct us only to continue our endea⯑vours, until it is brought to ſuch a ſtate as to be but ſlightly inconvenient. When the healing is far advanced, and after an iſſue [17]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 ap⯑plications, 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 in⯑convenient. On the other hand, if as the cure advances no difference is obſerved in our patient's ſtate of health, but what is ra⯑ther for the better, may not our endea⯑vours to completely heal the ſore be ſafely purſued? Which if we are ſo happy to ef⯑fect, [18]leaving an iſſue in the thigh, to be carefully attended to for ſome time, will make us eaſy reſpecting any future conſe⯑quence.

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 ſup⯑port, if freed from pain, would earn the bread of comfort! What pleaſure would many mothers find in performing the neceſ⯑ſary taſk of care for their, perhaps, yet ten⯑der offspring: Or, ſuppoſing the parents free from what would be their pride, in be⯑holding their children in the full uſe of their limbs! If I appear too earneſt, the im⯑portance 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 ne⯑ceſſary. 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 appear⯑ance of the ſore to the perſon much con⯑verſant 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 hap⯑pineſs to poſſeſs a true ſpecific in mercury, and as the mode of adminiſtering this va⯑luable medicine muſt be ſuppoſed to be [20]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 ad⯑miniſtering it has rather tended to prove it very uncertain; for although external ſymp⯑toms will from its uſe generally ſoon diſ⯑appear, 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 ul⯑ceration, 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 aſſiſt⯑ance.

The efficient cauſe by a judicious mer⯑curial courſe being removed, the ulcer uſually [21]changes its ſtate, as in the manner before deſcribed; and although the degree of cal⯑loſity 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 effec⯑tual recovery of health, and prove of great aſſiſtance in compleatly healing the ulcer.

Another yet more formidable evil too fre⯑quently 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 ſcro⯑phulous taint to their children's children? what more than ſingle cauſe have we then to [22]lament "That dreadful malady, the ſevereſt ſcourge with which in this life offended Heaven chaſtens the indulgence of criminal deſire^*" ever was tranſplanted from Ame⯑rican 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 diſ⯑covery 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 fu⯑ture 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, [23]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 ſuc⯑ceſsful 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 ill⯑conditioned: 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 [24]limb when the ulcer has been of long con⯑tinuance likewiſe appear much relaxed.

That the lymphatic veſſels are the imme⯑diate ſeat of ſcrophula is an opinion now ge⯑nerally received; that debility of the conſti⯑tution in general, is always connected with this diſeaſe, attentive obſervation will cer⯑tainly 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 be⯑fore any thing is ſaid on the external treat⯑ment, 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 re⯑commended by Dr. Mead in this diſeaſe, ſeems to have little better claim to our at⯑tention; decection of the woods and me⯑dicated lime-water that are frequently ſer⯑viceable [25]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 diſ⯑eaſe, loſe their force; even that lately ſo very faſhionable medicine, extract of hem⯑lock, has perhaps never been found to en⯑tirely 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 cu⯑rious 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 [26]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 ex⯑perience would inform us many now neglect⯑ed herbs poſſeſs great efficacy^*. Dr. Arm⯑ſtrong in his account of the diſeaſes moſt [27]incident to children, deſcribing ſcrophulous tumours in the neck, &c. has a paſſage which I cannot refrain taking the freedom to tran⯑ſcribe: "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 ſword⯑graſs, 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 con⯑tinues ſometimes for two or three hours or more; and I have heard of ſome very ob⯑ſtinate chronical and periodical tooth-achs and head-achs having been removed by this diſcharge, after a variety of other remedies [28]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 ex⯑tremely well, even upon ſome tumours of long ſtanding. It has occurred to me ſome⯑times 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 ſtand⯑ing.

What effect the application of vervain root in the manner directed by Mr. Morley would produce in this ſpecies of ulcer, I [29]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 con⯑viction 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 [30]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 re⯑laxed 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 ſa⯑tisfaction to obſerve a ſore in the leg that almoſt daily enlarged, where the fibres ap⯑peared [31]pale and much relaxed, and the diſ⯑charge 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 diſ⯑charge 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 in⯑ducing 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 infor⯑mation be contributed, my endeavours will be abundantly repaid.