Of the Treatment of the Ulcerative Action.
Suppuration is a natural termination of inflammation; and the ulcerative action is invariably induced by the suppurative, unless this remain chronic. The ulcerative action is to be considered as in part a restoration of the natural one; for we find, that it produces a restoration of the structure, granulations being formed by the vessels which formerly supplied the organic particles, whilst the interstitial vessels still yield a morbid fluid, called pus; but this they cease to do, whenever they again are placed in the natural situation; that is to say, whenever they become covered with the granulations, or are rendered interstitial. In proportion, then, as granulations are formed, a certain number of vessels are rendered interstitial, so that the discharge gradually diminishes, until at last it ceases; for, when we come to the formation of a cuticle, we have very few interstitial vessels left, the skin having naturally few. At this time, the one set of vessels having completed their action, and the part being restored, the other also resume their action, and a thin exhalent fluid is thrown out by the new cuticle, which keeps it soft and moist, and which is the natural insensible perspiration. The action of the two sets of vessels, then, is dependent on each other; and, whenever one is diseased, the other becomes also more or less so.
GENUS I.
Of the Healthy Ulcer.
From these remarks, as well as from those which were formerly made, it will appear, that a healthy ulcer has a natural tendency to heal, and that we ought only to be careful not to interrupt the natural progress, nor allow the action to flag.
In this genus of ulcers, the bottom of the sore seems to be paved with a number of small fleshy points, with minute interstices betwixt them, or surrounding their bases. These are of a red colour, with a slight shade of the purple, and are wet with a yellowish fluid, which is called pus; but which must of necessity differ from the fluid yielded by suppuration. This separates freely from the surface, when it is wiped or touched with a sponge, and then the granulations may be distinctly observed[47]. The margins are smooth, thin, and a very little rounded, that is to say, are almost imperceptibly raised above the granulations, a circumstance which is essential to this ulcer, because, were they both on the same level, it would show, that the cicatrizing process did not go on properly; for, whenever the granulations rise to the level of the surface, they ought instantly to form skin. This cicatrix, which extends gradually from the circumference to the centre, is of a pale red colour; but the integuments immediately beyond it are white, and of the natural appearance. Sometimes, from a slight deviation or imperfection, one spot of the disk rises to the level sooner than the rest; but, in this case, it immediately skins, and the cicatrix extends from this in the same way as from the circumference, until they both meet. The sore is free from pain, the only sensation being a slight degree of smarting, or itchiness.
The treatment of this ulcer is very simple; for, in most cases, it is only essentially necessary that we prevent the operation of hurtful causes. We defend the part, by covering it with a soft pledget of lint, and keep it warm. When the cicatrization has commenced, it may be assisted by using an ointment containing any harmless powder, in such a proportion as to form a paste or scab upon the part[48], by which we afford an artificial covering, which remains in close contact with the granulations; and, by thus bringing them nearly into the same circumstances as when skin is formed, the cicatrizing action is accelerated. The same effect is sometimes produced, by allowing the pus to form a scab over superficial sores, by exposing them to the air, without any covering.
Dry lint is a very useful application; but, as it is apt to stick to the granulations, and tear them, when tender, it ought always to be well moistened before removal, which should be attempted slowly.
Mild ointments, such as the simple cerate, are frequently employed; but they must be free from all rancidity, otherwise they fret the skin, or injure the sore. In general, they are less useful than dry lint. When we do employ them, they ought to be applied only to the granulations and cicatrix, and not to the sound skin. More frequently we use these ointments spread on a pledget of linen, to keep the dry lint on the sore.
Poultices are also recommended in these cases; but they possess no peculiar advantage, and are apt to make the part feeble, and more likely to break out again.