Part 6

Sweating is perhaps to the general hectic action what the suppuration is to the local one; and, therefore, can only be stopped by influencing this action.

It is not yet discovered that any remedy has a specific power of removing the hectic, or diseased formative action, more than the local purulent one; and, therefore, we are obliged solely to trust to these already mentioned, which have a natural tendency to increase the healthy action, or induce one nearly similar to it, and especially to a proper local treatment, by which we remove the exciting cause.

A diet solely animal has been proposed in that peculiar species of hectic which accompanies diabetes; but whether it would be equally useful in other species remains to be determined.

When these remedies fail, and the disease seems to continue, or increase, in spite both of general and local remedies, then we must, if it be practicable, remove the diseased part by an operation; and, in doing so, we must remember, that delay beyond a certain period is dangerous; because the general action becomes so rooted, and the strength so reduced, that recovery cannot take place. Operating in these circumstances, therefore, can only hasten death. The wound will not unite nor heal, and the general action will continue unabated.

When the local action is specific, the general one is also different from the simple hectic; and, therefore the remedies which are useful in simple hectic will not be of equal advantage in these cases, unless a specific remedy be conjoined, as, for instance, mercury prudently exhibited in the venereal hectic, dependent upon a neglected local complaint. The most frequent instance of specific hectic is the scrophulous; for the cure of which we possess no remedy which acts with certainty. Whenever, therefore, the local complaint cannot be cured, and the hectic increases, we must, if possible, remove the diseased part; after which, the general action, notwithstanding its specific nature, most commonly declines; but the constitution still remains, as formerly, scrophulous, or even more so than before. That this is the case, would appear from the following fact: If a person slightly scrophulous, although originally sprung from a scrophulous stock, or in whom the constitutional disease seems to be disappearing, in consequence of intermarriages, &c. has, by means of a local injury done to a joint, &c. the scrophulous action excited, and consequent hectic, that person will, after cure, have the tendency to scrophula stronger in him than formerly; and the disease will even frequently be communicated to his children with its original violence.

When this disease attacks the lungs, as it too frequently does, then, until a specific remedy for scrophula be discovered, no cure can be obtained. Simple ulceration, or suppuration of the lungs, however, and consequent hectic, may be cured, though not in every instance.

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. 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.

Whenever the discharge does not separate completely from the surface, when it is wiped, but part of it remains, like a film, or jelly, betwixt the granulations, or on particular spots, we may be sure that the action is not healthy.

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, 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.

Simple ointment, rubbed up with a fourth part of its weight of finely levigated calamine, or flowers of zinc, makes a useful application. Mr. Bell recommends, amongst other remedies, a saturnine ointment; but, if this produces any specific operation, it must be a hurtful one, injuring the action.

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.

Moderate pressure, by keeping up the action, is generally of service; but it is still more necessary when the action begins to flag, or becomes stationary. In this case, a compress ought to be placed over the sore, and the whole member rolled firmly round with a cotton bandage or, what will be still more useful, the part should be encircled with strips, spread with adhesive plaster, in the way which will afterwards be mentioned. Pressure acts by taking away the condition of vacuity; it forms an artificial covering and interstices for the superficial granulations, by which the natural process of forming granulation and skin is greatly assisted. The parts are, in this way, not only more quickly formed, but also in greater perfection; and their powers of action are greater. The cure is therefore more permanent, and the part is not so apt to die, or ulcerate again, as when healed with simple dressings.

This practice, which is useful in ulcers which from the first are healthy, is still more necessary in curing those which were formerly diseased, but have now become healthy; because, in them, the action is still more apt to flag.

The healing of large healthy ulcers which succeed to wounds, &c. will also be much hastened, if we artificially diminish the size of the cavity, and procure contact. Whenever one part can be brought in contact with another, it ought to be done, if the figure and functions of the part be not thereby injured, or if pain be not produced by doing so.

The older authors, from a mistaken theory, never allowed the action to proceed uninterrupted, or never co-operated with it in a rational manner. In every ulcer, it was necessary, first, to digest, or suppurate it, which was done with turpentine, or basilicon; next it was to be deterged with turpentine, mixed with yolk of eggs, or by the red precipitate; then it was to be incarned by sarcotics, such as tincture of myrrh and aloes, balsam of Peru, frankincense, &c.; lastly, the surface was to be dried into a callus, with dragon’s blood, white-lead, chalk, &c. These plans have, however, been long laid aside; but some practitioners still advise the use of styptics and spirit of wine to produce a cicatrix; they forget, however, that skin is formed by a different process than corrugation.

The diet ought to be good, in all cases of ulcers; but spiritous liquors, and the irregularities of life, must be avoided.

In ulcers of the legs, if pressure be employed, rest is not absolutely requisite; but, if this be not used, no cure can be obtained, if the patient walk about. Even if the adhesive plaster be applied, we ought not to allow of so much motion as to produce fatigue, or any uneasiness in the sore.

The treatment, then, of this genus of ulcers, may be comprised in two aphorisms.

First, When the action is, from the first, healthy and vigorous, and is continuing so, all which is essentially necessary, is to defend the part, and prevent the operation of any cause which might injure the action, such as cold, too much heat, mechanical irritation, &c. This may be done, by applying a bit of dry lint, or a rag spread with simple ointment, and wrapping the limb round with a flannel roller. But, if the action begins to flag, as it often does in large ulcers, or if the process become stationary, we must then indispensibly have recourse to gentle pressure.

Second, When the action has, at any one period, been diseased, or too low, but has been restored to a proper state, we must of necessity continue gentle pressure, and treat the sore as if the action were stationary, although it may not be so.

GENUS II.