WHOEVER has been at all conversant in the practice of Surgery, or has at­tended an Hospital, must have frequently ob­served 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 ef­forts of the healing art; but when the ulcer is of long standing, and the person a little ad­vanced 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 un­frequent, if the constitutional fault, which [Page 4]disposes to aggravate and continue this dis­ease, is not properly removed, although the sur­geon should be so successful as in appearance to heal the sore, that on resuming usual ex­ercise, in the course of a few weeks, the part becomes daily more painful, the tender co­vering 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 un­fortunate sufferers being those, who are ne­cessitated 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 [Page 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 cer­tain 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, [Page 6]which extends two fingers breadth every way from the edges of the sore, over this a ban­dage; 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 con­stitutional, 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, [Page 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 incon­venience, provided any quicker, and equally safe mode can be proposed.

This is the most simple state of ulcera­tion. 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 flan­nel wrung dry from a decoction of worm­wood, 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 com­mon bread and milk poultice only is applied, (which should be renewed at least three or [Page 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 re­moved, the discharge wears a better appear­ance, 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 basi­licon 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 ab­sorbent vessels in parts thus hardened, may be considered almost impervious, we have no good reason to expect this will effect any [Page 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 ac­tion 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 ne­cessary to rub them with lunar caustic either once a day, or every other day, in order to destroy the callosity. It must here be un­derstood that the patient uses every endeavour to enjoy the advantage of entire rest.

This state of ulceration being generally con­sidered as attended with some constitutional fault, while the means to heal the sore are em­ployed, 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 [Page 10]Scorbutic; not as the term is connected with the sea scurvy, but that general ap­pellation used for most kinds of eruption, discolourations of the skin, &c. The me­dicines 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 re­medy capable of effecting great changes in the constitution; but when it is considered that sulphur joined with mercury almost en­tirely 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 com­position of a similar kind, may be supposed to have no better effect. Nitre is another me­dicine sometimes administered; this possess­ing a sedative quality, often powerfully abating inflammation, and acting, in a proper dose, as a diuretic, is doubtless in [Page 11]many cases an excellent remedy. But other qualities seem to be wanted for the cure of this kind of ulcer. Calomel like­wise, which is sometimes given in a small dose for three or four nights, and then worked off with a brisk purge, tho' fre­quently repeated, generally fails of produc­ing 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 con­sequence, we have a most noble and almost certain corroberant in the Peruvian bark; but this is likewise given to remove the con­stitutional 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 ad­minister [Page 12]the bark, a dose of which should be taken three or four times a day, a more nu­tritive 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 con­siderable benefit; or salep ^* given to the quan­tity of half an ounce daily in a decoction ^‡ of [Page 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 ad­ministering Peruvian bark, and allowing a more nutritive diet, we will suppose the sore is become less, the callous edges nearly re­moved, 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 cover­ing disappear, and the sore become enlarged. Are we to seek a remedy, in this situation of the disease, from internal means? Or are dif­ferent 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, [Page 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 ap­plication when the ulcer (however deep) ap­pears 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 [Page 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 attend­ed 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 bow­els, asthma, and other ill consequences have been observed to follow the entirely sup­pressing 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 dis­charge is much lessened, will enable us to judge of the safety of perfectly healing the sore, or direct us only to continue our endea­vours, until it is brought to such a state as to be but slightly inconvenient. When the healing is far advanced, and after an issue [Page 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 ap­plications, 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 in­convenient. On the other hand, if as the cure advances no difference is observed in our patient's state of health, but what is ra­ther for the better, may not our endea­vours to completely heal the sore be safely pursued? Which if we are so happy to ef­fect, [Page 18]leaving an issue in the thigh, to be carefully attended to for some time, will make us easy respecting any future conse­quence.

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 sup­port, if freed from pain, would earn the bread of comfort! What pleasure would many mothers find in performing the neces­sary task of care for their, perhaps, yet ten­der offspring: Or, supposing the parents free from what would be their pride, in be­holding their children in the full use of their limbs! If I appear too earnest, the im­portance 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 ne­cessary. 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 appear­ance of the sore to the person much con­versant 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 hap­piness to possess a true specific in mercury, and as the mode of administering this va­luable medicine must be supposed to be [Page 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 ad­ministering it has rather tended to prove it very uncertain; for although external symp­toms will from its use generally soon dis­appear, 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 ul­ceration, 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 assist­ance.

The efficient cause by a judicious mer­curial course being removed, the ulcer usually [Page 21]changes its state, as in the manner before described; and although the degree of cal­losity 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 effec­tual recovery of health, and prove of great assistance in compleatly healing the ulcer.

Another yet more formidable evil too fre­quently 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 scro­phulous taint to their children's children? what more than single cause have we then to [Page 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 Ame­rican 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 dis­covery 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 fu­ture 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, [Page 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 suc­cessful 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 ill­conditioned: 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 [Page 24]limb when the ulcer has been of long con­tinuance likewise appear much relaxed.

That the lymphatic vessels are the imme­diate seat of scrophula is an opinion now ge­nerally received; that debility of the consti­tution in general, is always connected with this disease, attentive observation will cer­tainly 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 be­fore any thing is said on the external treat­ment, 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 re­commended by Dr. Mead in this disease, seems to have little better claim to our at­tention; decection of the woods and me­dicated lime-water that are frequently ser­viceable [Page 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 dis­ease, lose their force; even that lately so very fashionable medicine, extract of hem­lock, has perhaps never been found to en­tirely 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 cu­rious 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 [Page 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 ex­perience would inform us many now neglect­ed herbs possess great efficacy ^*. Dr. Arm­strong in his account of the diseases most [Page 27]incident to children, describing scrophulous tumours in the neck, &c. has a passage which I cannot refrain taking the freedom to tran­scribe: "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 sword­grass, 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 con­tinues sometimes for two or three hours or more; and I have heard of some very ob­stinate chronical and periodical tooth-achs and head-achs having been removed by this discharge, after a variety of other remedies [Page 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 ex­tremely well, even upon some tumours of long standing. It has occurred to me some­times 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 stand­ing.

What effect the application of vervain root in the manner directed by Mr. Morley would produce in this species of ulcer, I [Page 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 con­viction 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 [Page 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 re­laxed 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 sa­tisfaction to observe a sore in the leg that almost daily enlarged, where the fibres ap­peared [Page 31]pale and much relaxed, and the dis­charge 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 dis­charge 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 in­ducing 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 infor­mation be contributed, my endeavours will be abundantly repaid.