Second, Whenever this ceases to produce any farther effect, or the action relapses, and begins to go backward, we must lay aside the pressure for a time, and dress the sore with some of the stimulating applications above mentioned, particularly the nitro-mercurial salts; and these, in their turn, must be laid aside, when they cease to produce a good effect, and the pressure be again had recourse to.
Third, When we use stimulating dressings, we must attend to the effects which they produce on different parts of the sore, and dress these differently, according to their condition. We must likewise proportion the strength of application to the state of the general action. Our remedies ought to smart most when the action is most torpid, and the smarting ought to continue longest; but, when the action has begun to be more perfect and vigorous, the same application will often be too strong.
Fourth, We must, in conjunction with this general plan, attend to particular morbid structures, which may be produced by the particular state of the ulcer, and which may react on it. The chronic thickness and hardness of the integuments, are best removed by pressure, and gentle frictions; but the restoration of the natural structure is very tedious. Callous edges are likewise best removed by pressure. When this fails, caustic must be repeatedly applied. Varicose veins may be palliated by firm bandages, but are, in general, after they have continued long, only to be cured by an operation.
Fifth, When chronic ulcers can be healed, it is useful to form an issue, in order to keep up the accustomed secretory action; but these issues have little effect in advancing the cure.
GENUS III.
Of the overacting Ulcer.
This genus comprehends two species: First, that in which the granulating, or purulent process is morbidly increased, or the two parts of the ulcerative action, the granulating and the purulent, do not correspond, or bear the same proportion to each other that they do in a healthy ulcer: Second, that in which a state of general acute overaction takes place, both parts of the ulcerative action being equally affected, and rendered diseased.
For the illustration of the first species, I may remark, that there are some actions performed by particular parts of the body which are apparently simple; but there are others which are complicated, and consist evidently of different parts, which, in the aggregate, form a peculiar action, but which action may be modified according to the degree in which these different parts exist. Thus, there are various parts which, when taken together, form the inflammatory action, heat, redness, swelling, &c.; but these may, in certain cases, exist in different proportions. The ulcerative action is a complicated one, and consists of the secretory and organising action, or the purulent and granulating. These, in a healthy ulcer, bear a certain relation to each other, and are at all times so connected, that, when one part is injured, the other is also affected; but the one part may be affected more than the other. In the indolent ulcer, or that in which the action is too low, both parts are most commonly (at least after some time) equally affected, and a state of universal diminution, and consequent imperfection, takes place; but, in the beginning of this state, that is to say, when the healthy ulcer is first becoming diseased, and when the unhealthy condition has made little progress, it is not uncommon to observe an inequality in the action, or the granulations more affected than the discharge. In this genus of ulcers, however, the inequality is more striking, and frequently more permanent.
It is worthy of remark, that though the granulating action may be increased beyond the purulent one, that yet the purulent one never exists in a state of overaction without a correspondent affection of the granulating action; in which case, very different effects and symptoms are occasioned, and the second species of overacting ulcers is produced.
The first species has generally been described under the name of the fungous ulcer, or ulcer with hypersarcosis. The granulations are soft and indistinct. They are imperfectly formed, and, therefore, do not possess the pointed appearance which they exhibit in health; nor have they equal powers of action, nor longevity. They are formed quickly, and rise to a greater or less height above the level of the surrounding skin. The margins are generally soft, tumid, and of a dull red colour. The discharge, if there be no carious bone, is tolerably thick, and of a white colour, and not in greater quantity than would be yielded by a healthy ulcer of the same size: The quantity is even sometimes less. The pain, unless when a bone is diseased, is seldom considerable. This species admits of two varieties. In the first, the granulating process is increased, in consequence of some affection of the action, which is independent of any mechanical cause. In this case, the fungus is generally pretty firm, but commonly pale, and the discharge tolerably good. In the second variety, the granulating process is increased, in consequence of some mechanical irritation underneath, such as a piece of carious bone; and, in this case, the fungus is softer, and less firm; it is of a redder and more lively or fiery colour, and is sometimes covered, in particular parts, with spots of lymph; it bleeds upon the slightest touch. The sore is generally painful, and the discharge thin, serous, and of a fœtid smell, whilst we can frequently perceive at least one small foramen on the surface which leads down to the bone, and through which it may be felt to be rough. Out of this is discharged a thin matter from the bone, of a brownish colour, somewhat like soup, and more or less different from the discharge from the rest of the surface. These luxuriant granulations, however, must not be confounded with those which, at a later period, come from the bone itself, after it has begun to ulcerate. These are generally of a more florid red colour, though sometimes pale, and rise up either through chinks of the bare caries, or from such portions as are denuded by a previous exfoliation. They have, in general, a more pointed appearance than those which arise from the soft parts, so that, in many cases, the fungus resembles the surface of a strawberry, being rough. This variety may be induced quickly, the bone being injured, at the same time that the soft parts are affected; but, at other times, and perhaps more frequently, the bone becomes diseased, in consequence of the continuance of a simple ulcer immediately over it; as, for instance, on the tibia. In this case, the ulcer, which perhaps was formerly indolent, now changes its nature.