Elements of Surgery

by Robert Liston

OF ULCERS.

By ulcer is generally understood a breach of continuity in the soft parts of the body, with secretion of purulent or other fluid. But as suppuration may be independent of ulceration, so may we occasionally see a loss of substance like an ulcer on the surface of parts, without the production of pus, or any other morbid secretion, of which some instances are noted in the remarks on Atrophy of Articular Cartilage. Mr. Burns, in his excellent volume on the Principles of Surgery, has extended the term to the reparative process, as well as the destructive; this, if adopted, would lead to confusion and misapprehension.

Ulcers vary much in disposition and appearance, follow wounds, abscesses, sloughing, eruptions, &c., and often occur without any previous læsion of the surface. Those most generally met with are comprehended in the following classes:—1. The simple purulent ulcer, or healthy or healing sore. 2. The weak or sluggish ulcer,—a sore with undermined integuments and an unhealthy state of the cellular tissue. 3. The indolent ulcer,—a sore with hard elevated edges, and presenting little or no appearance of reparation. 4. The irritable ulcer,—a sore with over-action, and generally affecting only the mere surface of the true skin. Besides these, there are sores connected with diseases of the bones, and others arising from specific action; some are complicated with a varicose state of the veins: the former have been already treated of; the latter are reserved for consideration. Ulcers change their characters, as from simple to irritable, and from indolent to inflamed; the change depends on situation, on the state of the constitution, and on the treatment which they receive.

I. The appearances of the first class were described when the healing of wounds by granulations was considered, p. 173. They heal more readily on the upper extremities, on the face, neck, and trunk, than on the lower limbs; for in the former parts the circulation is more vigorous, the natural processes of cure proceed more easily, and are less liable to interruption. The sore only requires rest, a clean condition of the surrounding parts, mild and light dressings, and moderate support; dry lint or lotions are preferable to ointments, since the latter are apt to irritate by their rancidity. When the sore is of considerable size, and there is a tendency in the granulations to rise above the level of the surrounding skin or cicatrix, the edges may be protected by very narrow slips of fine old linen or cambric, spread with fresh spermaceti ointment or cold cream; a pledget of dry lint is then laid on, and retained by a roller. The dressings thus arranged do not adhere, and the tender cicatrix is not ruffled and disturbed; or a piece of pierced linen spread thinly with unirritating ointment may be placed over the sore, and above that dry lint. When the sore has contracted to a small size, and some powder, as starch or calamine stone, or a piece of dry lint, may be applied, so as to allow a scab to form for the protection of the subjacent surface; but this will, in most cases, be better accomplished by touching the surface lightly with lunar caustic or blue stone; the fluids on the part are thereby immediately coagulated, a crust is quickly formed, and by covering it with charpie, it is retained in its situation, whilst the process of cicatrisation proceeds beneath it: if a small quantity of matter should be secreted, it readily escapes by the sides of the crust, without disturbing either it or its covering; the limb should be raised above the level of the trunk. Sores on the lower limbs are always difficult to manage. The reparative process is tedious, on account of their situation; the parts are at a distance from the centre of circulation, their action is weak, the return of blood is tardy, and the same facility is not afforded of restraining the motions of the part as in the upper extremities. In persons of a good constitution, however, the simple purulent sore often heals speedily, even in the lower limbs. Before cicatrisation can take place, it is essential that the granulating surface should be on a level with the sound surface around; this soon takes place when a favourable position is observed, and the part is kept at rest; but by neglect, the new matter is often absorbed. Again, the healing process cannot advance where the granulations are exuberant, large, and flabby, and have risen above the proper level: they must be kept in check by due compression, and by astringent lotions, containing salts of zinc, copper, &c. The constant meddling with sores, the touching them with this, that, or the other caustic, is much to be reprobated. Should it be necessary to destroy granulations, and bring them down to the surrounding surface, one good rubbing with the blue stone will generally suffice. If the ulcer is large, the granulations close to the cicatrix should only be destroyed, leaving the centre to be dealt with as the cure advances.

During the cure, the patient must be a good deal confined to the recumbent posture; when erect, a bandage or laced stocking must be applied to the limb; thus the return of blood is assisted, swelling is prevented, and the affected parts placed in a state of comparative rest. Much pressure ought to be avoided, as it is apt to produce bad effects upon the sore, causing absorption of the granulations, thin bloody discharge, and great tenderness of the surface. After cicatrisation, the scars may be absorbed, and sores reproduced, by external injuries, or an unhealthy state of the body; and so much does the state of a sore depend upon that of the general health, that the one is a good index of the other.

II. In the second class of sores, or those with weak action, the granulations are flabby, of a pale colour, and possessed of little sensibility or vascularity; the discharge is gleety, and the surface is liable to be destroyed by ulceration or sloughing, upon the slightest excitement of the circulation in the part. The surrounding integuments are generally of a bluish colour, in consequence of their separation from the subjacent parts; and in several places of the neighbourhood, small, unhealthy, detached abscesses may exist; at some points of the sore, glairy fluid is seen to ooze out on pressure, and a probe can be passed pretty deeply into the cavity of an abscess in the soft parts beneath. These sores may arise from an unhealthy condition of the cellular tissue, taking place spontaneously, or following slight injury; they are attributable to the state of the constitution, and may result from an ulcer, originally of a healthy character, which has remained long open, in consequence of its great size, or other impediments to its contraction.

It is the business of the surgeon, in cases of this description, first to obtain a sound foundation, by destroying the unhealthy skin and cellular tissue; the free application of caustic potass will answer this end most readily and effectually. Its application is attended with considerable pain, but the practice is more successful and less severe than the removal of the unsound parts by the knife or other means. The small abscesses may be all freely laid open; the diseased cellular tissue may be cut into, or cut away; in short, incisions may be made in all directions, and in every portion of the affected part; but still it will be found that the granulations, as they appear, become pale and flabby, that they spring from a loose and powerless base; matter will again collect; the surrounding skin will again be undermined; no progress will be made towards soundness. But by attention to the state of the constitution, and the application of potass, the neighbouring sound parts have their actions roused, and the healing is carried on rapidly. After its application, a poultice may be applied for a few days, and followed by water dressing, and then stimulants, both internally and externally employed according to circumstances, the parts being all along well supported. The long continued use of warm fomentations, or poultices, is prejudicial, as tending to diminish still farther the action of the parts; ointments can be of little service, and will generally do harm.

III. Indolent ulcers, which have long existed, are frequently met with on the lower limbs. Their margins are thick and insensible—their surfaces smooth, hollow, and of a pale colour—the discharge is scanty, and adheres to the surface. A sore, having been long open and neglected, degenerates into this state. Poultices are to be applied for a day or two, to clean the surface, promote the discharge, and soften the callous margins. This is the more necessary, if, as is often the case, the sore, or the surrounding integuments, are inflamed when the patient applies for relief. Afterwards, the applications must be of such a nature as to moderate the discharge and keep the granulations firm and healthy. In such cases only is adhesive plaster applicable, and in them it produces the most beneficial results. Supposing the ulcer to be situated on the fore and middle part of the leg, a bandage should first be firmly applied from the toes to a little below the sore; the ulcerated part of the limb is then encircled by narrow strips of adhesive plaster, tightly drawn, and with the extremities of each strip crossing immediately over the ulcer. A pledget of tow is placed on the plasters to absorb the discharge, and the bandage is brought over dressings, and continued for some way upward. By this application, the margins of the sore, it is supposed, are brought nearer to each other, and the ulcerated surface diminished; the sluggish granulations and the subjacent parts are stimulated, and a more vigorous action being excited, the process of reparation proceeds speedily and effectually; the surrounding parts, previously turgid and œdematous, are by the pressure brought to the same level with the newly-secreted matter, and new skin is quickly formed. In the previous state of matters, the old skin was much elevated, and an action was in progress, causing a continuance of that elevation; by the compression, the whole limb is properly supported, serous effusion prevented, absorption excited, and œdema removed; the livid swelling of the lower part of the limb, which might arise from the tightness of the adhesive plaster, is obviated by the bandage being first applied. A feeling of uneasiness in the limb sometimes follows such dressing, but is of short duration; should it increase, so as to amount to pain, the elevation of the limb and the pouring of cold water occasionally over the dressings will soon restore the parts to comfort. Or the adhesive plaster may be slit up behind, immediately after its application; indentation of the limb being thereby avoided, and sufficient pressure at the same time kept up on the sore. If possible, the dressings ought not to be removed before the second day, as much irritation will be produced by their frequent renewal. The benefits arising from this mode of treatment are truly surprising; the slow and indolent ulcer is speedily converted into the simple purulent sore; the white and recent cutaneous substance encircles small pointed and florid granulations, which bleed from the slightest rudeness of touch; and the space formerly occupied by an unsightly sore is soon diminished to a small and firm cicatrix. It is only necessary to continue this mode of dressing so long as the granulating surface is below the level of the surrounding surface. Then the object being attained, the deranged state of the cellular tissue being got rid of, and the ulcer put in a state favourable for cicatrisation, the sulphate of zinc lotion not over strong may be resorted to; positive rest and support of the affected part being still enjoined and observed. In the old and debilitated, however, in whom the indolent sore most frequently occurs, the integuments remain purple and shining, and from very slight causes the cicatrix is absorbed, and breach of surface is reproduced.

These sores are often connected with a varicose state of the veins. In all such cases, a degree of compression on the affected limb must be maintained, both during the continuance of the sore, and after it has healed. The usual situation of such sores is on the leg, and the varicose state of the veins does not, in general, extend above the knee; in such cases, a radical cure may be attained (provided the patient wishes to encounter the attendant risks, rather than submit to a continuance of the disease) by effecting an obliteration of the saphena major vein. The manner of doing this, and its effects, were mentioned while treating of diseased veins. In some cases, the saphena minor is also varicose to some extent, the varices on which must also be obliterated. Sometimes as many as eight or ten needles must be applied, in pairs, before the circulation of a limb can be brought into a right state.

IV. In this fourth class of sores, or the irritable from over-action, the sore and its edges are of a jagged, irregular appearance, the discharge is thin and bloody, and considerable pain is experienced. This ulcer is very superficial, involving only the surface of the corium and the more sensible part of the integument, the papillæ, and extremities of the nervous filaments. They often succeed to scaly eruptions, and present a remarkable character and appearance, cicatrising in the centre, whilst they extend towards the circumference. The sore is often covered by an ash-coloured slough; on the removal of which, granulations arise, but these either again slough, or are removed rapidly by the ulcerative process. In the treatment of such sores, complete rest and soothing applications are the means on which most reliance is to be placed. Warm and soft poultices, such as those of arrow-root, fomentations, tepid water dressing, solutions of opium, or of extract of poppy, and the occasional use of a local vapour bath to the part, may be enumerated amongst the means best fitted to allay the irritable condition of the ulcer. When the surrounding integuments are swollen, red, painful, in short, evince marks of inflammatory action going on in them, the feelings of the patient will be rendered grateful, and the cure advanced, by abstraction of blood from the parts by punctures. When the nature of the sore is changed, and when cicatrisation has commenced, the treatment is similar to that of a simple granulating surface—light dressings, due support of the parts, and repression of exuberant granulations by the sulphate of copper. The nitrate of silver, applied in substance round and about the ragged edges, is of great service at an earlier period. This practice must be sparingly and seldom resorted to, but it does wonders when judiciously employed.