Dissertations on Inflammation, Vol. 2

by John Burns

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 recovery[53].

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 it[54], 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.