Y^IfifflEf
Li,*
^j-W"
i.*' .->>>
tf^M'S^vU
--M»
V- • '-r *"*£■
;X
A'
&
e


**/;
*   . • •

^k  A    ^Jft 

NATIONAL LIBRARY OF MEDICINE
         Washington
i
7-
c
\1  VA^ 
w 
 
 PRACTICAL OBSERVATIONS




           ON



       THE TREATMENT




           OF





ULCERS  ON THE LEGS. 
 
     PRACTICAL OBSERVATIONS



                  ON



        THE TREATMENT



                  OF



ULCERS  ON  THE  LEGS,



             CONSIDERED AS



  A BRANCH OF MILITARY SURGERY.
                         i

            TO WHICH ARE ADDED,


        SOME OBSERVATIONS



ON VARICOSE VEINS, AND PILES.




          FIRST AMERICAN EDITION.
)ME,
 BY EVERARDHOME, ESQ. F.R.S.

SURGEON TO THE ARMY AND ST. GEORGE'S HOSPITAL.
PHILADELPHIA
Jl&fyl
PUBLISHED  BY EDWARD PARKER,

       NO. 178, MARKET STREET.

     William Brown Printer, Church-alley.




              1811 
•1 
       TO HIS ROYAL HIGHNESS

           FREDERICK,

   DUKE OF YORK AND ALBANY,
  field marshal and commander in chief of
           his majesty's forces.
      Sir,
 JN o  surgical complaint, incident to the sol-
dier, has  deprived  his Majesty's service of
so many men as that of ulcers on  the legs ;  it
is  therefore  a disease, the effects of  which
your Royal Highness,  in considering the mi-
litary  resources of the country, must always
have seen with regret.

  From viewing the subject  in  this light,  I
have presumed to lay before your Royal  High-
ness the following pages ; in which an attempt 
VI           DEDICATION.
is made to diminish an evil so destructive to the
effective strength of the army.  I am the more
encouraged  to  address  them  to your Royal
Highness from having experienced, while un-
der your royal Highness's command upon the
Continent, a ready compliance with every ar-
rangement that was suggested for the relief of
the soldier, accompanied with anpearnest soli-
citude for his welfare.

   A  great part of my experience on this sub-
ject,  has been  acquired in Military hospitals,
and I now communicate  my  observations to
the Public,  from a  desire to be of use in this
the most common and necessary branch of Mi-
litary Surgery.

   The present work, I hope, will not be con-
sidered as unworthy of your Royal Highness's
protection, the honourable sanction of whose
name will show, that whatever may be its im-
perfections, the subject of it has attracted the
notice of your Royal Highness, and therefore is
highly  deserving of the  consideration of the
 General and Field Officers of the Armv. 
             DEDICATION.

  The support it may receive from the Com-
manding Officers of Regiments, excited  by
your Royal Highness's example, will also be
the  means of its engaging the study and atten-
tion of every military surgeon.
         I have the honour to  be,
         with the greatest  respect,
           Sir,
        your Royal Highness's devoted
           and most obedient
                 humble servant
                 EVERARD HOME.
vii 
 
TABLE OF CONTENTS.
                                    Page
Introduction    .       -       -       13
             CHAPTER I.
On the properties of Pus    -     -      25
            CHAPTER II.
General observations on ulcers on the legs 54
General distribution of ulcers into their
   species      ...       65
            CHAPTER III.
Of ulcers  in parts which have sufficient
  strength to cdrry on the actions necessa-
  ry for their own recovery             68
Applications considered with reference to
  this species of ulcer                   72
            CHAPTER IV.
Of ulcers in parts that are too weak to car- 
X         TABLE  OF CONTENTS.
                                        Page
   ry on the actions necessary for their own
   recovery                              76
Applications considered, with reference to
   this species of ulcer      -      -      86
              CHAPTER  V.
Of ulcers in parts  whose actions are  too
   violent to form  healthy  granulations ;
   whether this arises jrom the state of the
  parts  or of the constitution      -       95
Applications considered, with reference to
   this species of ulcer    -        -      106
              CHAPTER  VI.
Experiments and observations on the irri-
   tability of nerves, by which the spasmo-
   dic affections attendant upon irritable
   ulcers are accounted for       -       121
             CHAPTER VII.
Of ulcers in parts whose actions are  too
   indolent to form healthy granulations,
   whether this indolence arises from  the
   sthte of the parts or of the constitution 158
Applications considered, with reference to
   this species of ulcer       .     -      167 
         TABLE  OF CONTENTS.         XI
             CHAPTER VIII.

Of ulcers attended with some specific dis-
  eased action,  whether constitutional or
  local   -                            200
1. Of those ulcers which yield to mercury 203
2.  Of ulcers which yield to the use of dif-
 ferent preparations of the conium macu-
  latum, or hemlock     ...   206
3. Of Ulcers which yield to the application
  of salt water     -              -    209
4.  Of ulcers which yield to the use of the
  argentum nitratum     -       -    211
5. Of ulcers which yield to the use of arse-
  nic     -                           218
             CHAPTER IX.
Of ulcers attended with a varicose state of
  the veins of the limb, and the advantages
  derived in such cases from including the
  vena saphena in a ligature    -    -  223
Cases  of the vena saphena included in a
  ligature, to promote the cure of ulcers on
  the leg       -      -       -      245 
XII         TABLE OF  CONTENTS.
             CHAPTER X.
                                        Page
The effects of ligatures on varicose veins
  in cases of enlarged vena saphena, vari-
  cocele, and piles     ...     272
On tying the vena saphena  to render it
  less varicose.          -       -        273
On tying the spermatic vein in  cases  of
  varicocele       -       -             282
On tying piles so as to prevent the painful
  symptoms usually produced by that ope-
  ration         -       - -      -        290 
INTRODUCTION.
 W HEN we consider  the number of re-
cruits who are rejected,  and the number of
well disciplined men who are discharged from
the army  on  account of ulcers on the legs,
it must appear to be one  of the most impor-
tant duties of every military surgeon, to pay
particular attention to a complaint, which ren-
ders so many men unfit to perform the duties
of soldiers.

  It has been unpropitious to the  improve-
ment of the treatment of ulcers on the legs,
that they  have been universally admitted to
be the most unmanageable cases which be-
come  the  objects of surgery •,  that they are
                   B 
XIV          INTRODUCTION.
cases in which  the  most eminent surgeons
are two often known to fail in performing a
cure;. and, therefore, bring  no imputation of
want of skill upon  those practitioners who
happen to prove unsuccessful.

   This has  led  the younger part of the pro-
fession in the army to be too diffident of their
own abilities ; to despair of success where so
many have  failed;  and to  follow a  beaten
track,  in which so  little advance has been
made, that ulcers on the legs are not unjustly
considered as the opprobrium of surgery.

   Ulcers on the legs when regiments are em-
ployed on service, are too frequently conceal-
ed, and consequently neglected, till they have
increased to a  considerable size; and this,
in many instances, happens from  a desire in
the  soldier  to avoid his duty, or  to procure
his discharge.   In this way,  too  many men
have been finally lost to the  army.  When-
ever this  kind  of imposition  succeeds, it is
productive of much  greater  mischief than the
tess of  the  individual to the service,  by in- 
INTRODUCTION*
x'v
ducing other men, when dissatisfied, to make
similar attempts, which  otherwise would not
have  been suggested to their  minds.  It is
therefore  adviseable,  whenever there is  the
smallest  suspicion  that  any men have hurt
their  legs from  such motives,  to keep them
in the regiment, even when rendered unfit
for duty.

   If  the  idea that  this  disease is incurable,
prevails  in  a regiment, the soldiers will be
very ready to take advantage of such an opi-
nion ;  and the surgeon who admits of it,  will
not be induced to give cases of this kind the
degree of attention which is necessary to per-
form  a cure, or to detect those men who are
artfully counteracting his endeavours.

   As the difficulty in effecting a cure, applies
only  to those ulcers which  have increased to
a  considerable size,  or  have been long  in a
bad state; there should  be  a regulation in all
regiments, that the smallest ulcers on the legs
are to be immediately reported to the sur
geon; the non-commissioned officers of every 
 XVI          INTRODUCTION.
 company should  be required to enforce this
 regulation;  and all men  so reported, should
 remain under the  direction of the surgeon
 till perfectly recovered.

   A  regulation of  this kind  would be the
 means of saving many good men to the ser-
 vice,  and preventing "many others from leav-
 ing it; as ulcers  on the  legs,  in their early
 stages, admit of being  healed  even by sur-
 geons whose attention has not  been particu-
 larly directed to the subject.

   There is in many regiments, an unwilling-
 ness in the  commanding officers in compa-
 nies to have their men put into the regimen-
 tal hospital for slight complaints ; and those
 men who are not removed from their barracks,
 are so little  under the  controul  of the sur-
geon, that he does  not feel them intrusted to
his charge;  they are,  therefore, of course ne-
glected both by themselves and the surgeon.
 This is perfectly well known to be true ; and
in many slight cases of  disease may be pro-
ductive of no material harm; but since it is 
INTRODUCTION.
XVI
 generally allowed, that ulcers on the leg are
 so little in the power of the surgeon when they
 arrive at a bad state,  the commanding officers
 of regiments should put it into orders, that
 every man affected with such a complaint, is
 to be placed under the  sole management of
 the  surgeon; that the evil  may be encoun-
 tered in time, and the patients have a chance
 of being recovered.

   Men who have been cured,  and return to
 their duty, should be made to wear a bandage
 and compress for some time, as a support to
 the newly formed parts, and a defence against
 accidental violence.   A piece of thin tea lead
 may  be used  with advantage for  this  pur-
 pose-

   If ulcers on the leg,  when  neglected, are
 found in the country, to spread and become
 a  very serious  disease, it happens  in a still
 greater degree in the West Indies, where the
 slightest previous hurt  upon  the leg,  or a
 small ulcer, will, from the effects of fatigue
in that climate, in a very short  time, become
                   b 2- 
 XV111         INTRODUCTION.
 an ulcer of the worst description, and  render
 the  patient  entirely  unfit for service.   Too
 much attention, therefore, cannot be paid to
 the conduct of the soldier in hot countries, to
 prevent ulcers; and when they occur,  to put
 the men as soon as possible under  the direc-
 tion of the surgeon.

   At St. Lucia, during the  American war,  I
 had several conversations upon this subject
 with Dr. Young, physician to the army;  who
 had been formerly a regimental surgeon, and
 had served  in  the Windward Islands  in the
 year 1765, and the three following years. In
 that period he had made some remarks, which
 led him to conclude,  that tall men are  less
 able to bear the climate  of the West Indies,
 and are more liable to ulcers on the legs  than
 others.  As his observations are curious,  they
 are laid before the reader.

   Dr. Young observed, that in the 32d re-
 giment, there  were 145 tall men,  and  276
 short men.  That in the course of four years
22 were discharged from those  of the  first 
             INTRODUCTION.          XIX
description, and only 23 from the second, on
account of ulcers on the legs.  The  ulcers
were of such a nature as to be deemed incura-
ble  in  that climate.  Some of the patients
were obliged to  undergo amputation, to give
them a chance for their lives ;  others had so
many of the muscles and tendons  injured as
to render them,  ever after,  unfit for service.
The principal cause why tall  men are more
subject to  ulcers on the legs than short men,
Dr.  Young conceived to be the length of the
column of blood in their veins; which, by its
pressure, renders the legs less able to recover
when hurt  by  any violence.   He observed, at
the  same time,  that tall men are less  able to
support the heat  of the climate ;  and by losing
their general health,  are rendered more liable
to have ulcers on the legs.   From these re-
marks Dr.  Young concludes, that many lives
might be  saved,  by omitting  to send any
grenadier companies to the West Indies.

  After having made these observations on
the 32d regiment, Dr. Young went upon the
expedition against Martinique and the Havan- 
XX
INTRODUCTION,
na;  and was surprised to find that ulcers on
die leg,  in another regiment,  were less fre-
quent, although the mode of life, diet, and all
general circumstances were the same, and the
fatigue considerably greater.  This he was led
in some measure to attribute  to  the  circum-
stance of the men wearing half boots of cloth,
which defended the legs from many  slight
accidents  occasioned by  marching through
uncleared  paths, by kicks,  or the bites of
musquitoes.   They  also kept the  legs dry ;
and gave a support to the veins, which  wool-
len cloth gaiters, from their elasticity, will do
in a  greater degree than those made of leather
and linen.*

  The mode of treating ulcers on the legs ia
regimental, and other military  hospitals,  I
have had many opportunities of seeing, while
employed as an army surgeon; and have made
particular  inquiries from  those who  are at


  • Dr. Young did not mention whether the grenadiers were
more liable to a varicose state of the veins of the legs, but hi*
observations certainly imply that they were. 
              INTRODUCTION.           XXI
 present surgeons of regiments,  and find it to
 be still  the  same.  They are  commonly all
 treated upon one general plan.  If the ulcers
 are in a foul state, they are poulticed; when
 they become  clean, they are dressed.  The
 same kind of poultice is used to all foul ulcers,
 and the same kind of dressing  is used to all
 those  which put on a  more  favourable  ap-
 pearance.  If a new mode  of treatment for
 ulcers is at any time published  by a surgeon
 whose character is respectable, this  is tried.
 The result, in general, is, that in some cases
 it is found to answer;  in many  others it failsr
 and, upon the whole, usually  falls short of the
 expectation's  that had  been  raised.   It  is
 therefore  very soon thrown  aside;  and the
 old plan, though  allowed by every surgeon
 individually to be bad, is resumed.

   Such must of course, continue to be the
 case, while the disease remains uninvestigated;
 and the different  species of ulcers,  and their
 varieties arising from natural peculiarities, are
not understood.  Since, without such know-
 ledge, all  trials of different applications be- 
 XXU          INTRODUCTION.
 come so many random experiments, which,*
 by their too frequent failure, will discourage
 the practitioner from prosecuting so fruitless
 an inquiry.  With  a view to  enlarge  our
 knowledge, and to establish some general prin-
 ciples, that may guide us in the treatment of
 ulcers on the legs, an attempt is made to ar-
 range them under different heads, and to point
 out those distinguishing  characters of each
 species, which will make one mode of treat-
 ment  more  likely  to produce  a cure  than
 others of a different kind; giving an account
of those local applications of which  1 have
 had experience, and their particular  effects.

  By these means it is hoped, in some mea-
 sure,  to clear the way for those who may be
 led hereafter to take up this subject; and  that
an arrangement having once been made, under
which the  observations and detached facts
noticed by individuals may  be collected  in a
small  compass, the treatment of ulcers on the
 legs may in process  of time be very much
 improved ; and many cases of that kind cured, 
INTRODUCTION.
xxiii
which at  present are considered as beyond
the reach of surgery.

   A plan of this kind will be favourably re-
ceived by the surgeons of the army, who have
so many cases of this kind  intrusted to their
care.   It  will shew them the extent of  the
inquiry, and that very little has hitherto been
done.  It will point  out  also, how much it
is in the power  of every individuaHto add to
the stock of cur knowledge, and thereby ad-
vance his own credit and the public benefit. 
-   y
i 
CHAPTER I.
          ON THE PROPERTIES OF PUS."

     IN  considering the  properties  of Pus,  and
its effects upon the body, it is not intended to enter
minutely into  the opinions of either the ancient or
modern  authors  respecting it;  or to  examine the
arguments by which these  opinions have been  sup-
ported ;  but to endeavour,  by  experiments  and
observations, to investigate  the different parts of the
subject.

     It may not, however, be  improper  to  take
notice, that the most generally established opinion
of the nature of  Pus, till within the last thirty
years, has  been,  that it  was  composed of  both
solids and  fluids  ;  nor  is the  opinion, even now,
entirely exploded.   It was called, " true, or laudable
Pus;" to distinguish it from a similar discharge,

   * The following observations made part of a prize dissertation
printed in the year 1788, by  order of the Lyceum  Medicum
 Londinense*
                         c 
 26        ON THE  PROPERTIES OF PUS.
 supposed to be composed  wholly of fluids,  called
 Mucus.   Yet the  distinctions  between Pus  and
 Mucus have been very ill defined : there was thought
 to be a difference,  in their appearance to the  eye ;
 but  the  principal  mark of distinction  arose  from
 a breach of surface being believed necessary to the
 formation of Pus, but not of Mucus ;  consequently,
 when there was  no breach in the solids,  the dis-
 charge was considered to be only Mucus.

  This notion of Pus must have taken its rise from
 an idea that the solids of the part were broken down
 i»to  Pus.   The  physiologists, who formed  this
 theory, cannot, however, be said to have made their
 distinctions with great accuracy, since  the discharge,
 in consequence of  a  blister  being applied to the
 surface of the body, was admitted  to be  Pus ;
 although in such cases there is no loss of substance,
 and therefore the discharge should have been called
 Mucus.

  To ascertain a real  difference  between the  fluid
formed where there  is a breach in the solids, and that
met  with where  the surface  is  entire, has  been
considered an object meriting the  attention  of some
of our most eminent surgeons,  although the  fluid
formed  und6r both these  circumstances  will be
found to be precisely the same.   This inquiry must 
          ON THE PROPERTIES OF  PUS.         27

 have arisen from their adhering to the hypothesis
 which has been  mentioned; and which, not being
 founded upon the principles of the animal (Economy,
 can never explain, satisfactorily, any of the opera-
 tions in the living bodv.

   It will be found upon investigation,  that the ap-
 pearance of a discharge produced from the secreting
 surface of an internal canal, or excretory duct, when
 the  produce of  the  suppurative inflammation   is
 exacdy similar to a  discharge, in  consequence of
 inflammation, in any other part of the body.  The
 only respect in which they differ is, that in the one
 case there is no breach of surface, and in  the other,
 there most commonly appears to be one.  The one
 is suppuration alone ;  the other,  suppuration  at-
 tended by ulceration.

   It is intended  in the present  inquiry ; to collect
 those  properties  and  circumstances  which  have
 been ascertained respecting Pus ; and to endeavour,
 by investigating others not so well  understood, to
 render the history of it  more complete.

   Through  the whole of these  observations, Pus
will  be considered  as  a  fluid, whose formation
depends  upon a process  in the animal  ceconomy,
analogous to glandular secretions. 
28
ON THE PROPERTIES OF PUS.
   It is difficult to give a definition of any thing, the
 properties of which are not well ascertained ; but as
 it is necessary to particularize the substance which
 it is proposed to investigate under the term Pus, it
 may be defined to be a  whitish fluid, made up of
 globules,  and a  transparent aqueous  liquor.  Its
 production  depends  upon  inflammation  having
 previously taken place in some part of the  body,
 either in the common reticular membrane, upon the
 internal  surface of circumscribed cavities,  or the
 surfaces of internal  canals, which  form excretory-
 ducts of the body.

   Inflammation  is necessary for the formation of
 Pus ;  and although a   fluid, some-what  similar,
 is produced without any preceding inflammation, such
 fluid, not having all the properties of true  Pus,
 can be readily distinguished from it.
   Pus,  whether it is formed in  the  cellular mem-
 brane,  upon an investing membrane, or on the in-
 ternal surface of  an excretory duct, has exactly the
 same appearance, and  general properties : no dis-
 tinctions will therefore be made between Pus pro-
 duced under this  or that peculiar circumstance, be-
lieving  it, when  preceded by the same degree of
 inflammation in a healthy constitution, and when free
from any  extraneous  substances, to be the same
fluid : but as a  difference in Pus may arise from a 
          ON THE PROPERTIES  OF PUS.        29

variety  of causes, it  will be proper  first to mark
those properties which really belong to it in a heal-
thy  state of body j  and afterwards mention the
variations to which it is liable.

   Pus,  taken from a  healthy ulcer near the source
of the circulation, as on the arm or breast, readily
separates from  the surface of the sore, the granula-
tions underneath being small, pointed, and of a flo-
rid red colour,  and has the following properties :
it is  nearly of the consistence  of cream ; is of a
white  colour ; has a mawkish taste ; and when
cold, is inodorous ; but when warm,  has a peculiar
smell.  Examined in the  microscope, it is found
to consist of two parts, of  globules, and a transpa-
rent  colourless fluid  ; the  globules are,  probably,
white,  at least  they appear to have some  degree of
opacity : its specific  gravity is greater than that of
water : it does not readily  go  into  putrefaction :
exposed to heat, it evaporates to dryness ;  but does
not coagulate :  it  does not unite with water in  the
heat of the atmosphere, but falls  to  the  bottom ;
yet, if kept in a considerable degree of heat, rises,
and diffuses through  the water,  and remains mixed
with  it, even  after having been  allowed to cool;
the globules being decomposed.
   Pus  varies  in  its  appearance,  according to  the
different circumstances which  affect the  ulcer that
                      c 2 
30        ON THE PROPERTIES  OF PUS.

forms it, such as the  degree of  violence of the in-
flammation  ; also its  nature, whether healthy or
unhealthy ;  and  these  depend  upon  the state of
health and  strength of the parts yielding Pus.
  These changes arise more from indolence, and ir-
ritability,  than from  any  absolute disease : many
specific diseases, in healthy constitutions, produ-
cing no change  in the appearance  of the matter
from  their  specific  quality.    Thus  the  matter
from a gonorrhoea, from the small-pox  pustules, the
chicken-pock,  and from a healthy ulcer, has the
same  appearance, and  seems to  be  made  up of
similar  parts, consisting of globules floating  in a
transparent  fluid, like  common Pus,  the specific
properties of each of these poisons being super-
added to  those  of Pus.  Matter from  a cancer
may be  considered as an exception ;  but a can-
cerous ulcer is never  in a healthy state.

  In indolent ulcers,  whether the indolence arises
from  the  nature  of the  constitution, weakness of
the  parts,  or the nature of the  inflammation, the
Pus is  made up of globules, and  flaky   particles
floating in a transparent fluid ;  and these globules
and flakes are  in different proportions, according
!o the  degree  of indolence :  this is  particularly
observable in scrofulous abscesses,  preceded by a
= mall decree of inflammation.   That this flaky ap- 
          ON  THE PROPERTIES  OF PUS.        31

pearance is  no part of true Pus is well illustrated,
by observing, that  the proportion  it bears to the
globules is greatest where there  is the  least inflam-
mation ; and in those abscesses  that sometimes oc-
cur, which  have not been  preceded by any inflam-
mation  at ill. the contents are wholly  made up of
a curdly or flaky  substance, of different degrees
of consistence, which is not  considered  to be Pus,
from its not having the properties stated in the de-
finition of that fluid.

  The constitution and part must be in health to
form good Pus ;  for very slight changes  in  the
general  health are capable of producing an alteration
in it, and even of preventing its being formed at all,
and  substituting in its place coagulating  lymph.
This happens most  readily in ulcers on the lower
extremities, owing to the distance of the parts from
the  source of  the circulation,  rendering them
weaker.   And it  is  curious to observe   the in-
fluence, that distance alone from the heart has upon
the appearance of Pus.

  A man had a compound fracture of the right leg,
and  an  ulcer on the  ankle  of the  left j  he  was in
tolerable health, both the ulcers  looking  well.  An
attack of fever came on soon after, when the ulcer
on the  ankle ceased to form  good Pus, the matter 
32         ON THE PRORPETIES  OF PUS.
not separating readily from  its surface, while the
compound  fracture continued  to look very well;
but in twelve hours  more,  the  same change had
taken place in the opening of the compound frac-
ture,  which was about six inches higher up the leg
than the ulcer.

  In  irritable ulcers,  the discharge is often thin,
being principally made up of an aqueous fluid pos-
sessed of an irritating quality,  and containing few
globules ; such ulcers are commonly attended with
hemorrhage  from the  smaller  vessels, by  which
means the  discharge  is very  materially altered  in
its properties, is rendered acrid, and more  ready  to
run into putrefaction than  true  Pus.   We  find,
however, in many irritable  constitutions, the same
appearances that were mentioned to  take place  in
the indolent, the coagulating lymph  being thrown
out, and adhering firmly to the surface of the  ulcer;
therefore the appearance of  an ulcer alone will not
lead us to a correct judgment  of its nature, but
will only inform us whether it is healthy or unheal-
thy.

  Although these different appearances of Pus have
been noticed, from their being so connected with its
history as to deserve  attention, they are not  to be
considered as belonging to true Pus ;  but as arisine 
         ON THE PROPERTIES OF  PUS         33

from a defect in the process, whatever  it is,  by
which Pus is formed.

  As Pus has been supposed to have a corroding
quality, the  following experiments were  made, to
ascertain the  truth or fallacy of such an  assertion,
and it was found to be void of foundation,  and to
have arisen  from an inaccuracy,  which prevented
observers from seeing the distinctions between Pus
in a  pure  state, and   when  mixed  with  other
substances.
              EXPERIMENT I.

  A  comparative  trial was  made upon the  Pus
contained in an abscess, and  on Pus, and  animal
jelly out of the body.  The matter and jelly were
in equal quantities, and  contained in glass  vessels
kept nearly in the temperature of the human body.
To  make the comparative trials as fair as possible,
a portion of muscle, weighing exactly one drachm,
was immersed in the matter of a compound fracture,
in the arm  of a living man, and a similar portion
into some of the same matter out of the body ; also
a third portion into fluid calf's  foot jelly, in which 
34        ON THE PROPERTIES OF PUS.
 the animal substance was pure, having neither wine
 nor vegetables mixed with it.  These three portions
 of muscle were taken out once  every twenty-four
 hours, washed  in  water,  weighed, and  returned,
 again.   The results were as  follows :

   In 24 hours—the portion of muscle  in the ab-
 scess weighed sixty grains, was pulpy and soft, but
 quite free from  putrefaction : that portion immers-
 ed in the Pus weighed forty-six grains,  was pulpy,
 soft, and had a slightly putrid smell: the  portion in
 the  jelly weighed thirty-eight grains, was smaller,
 and firmer in its texture.

   In 48 hours—the portion of  muscle  in the ab-
 scess weighed thirty-eight grains, and had under-
 gone no change : that in the matter weighed thirty-
 six grains, was softer, and more putrid :  that in the
jelly thirty-six grains, and smaller.

   In 72  hours—the portion of muscle in the abscess
 weighed  twenty-seven grains, was drier, and firmer:
 that in the matter eighteen grains, and was rendered
 fibrous and thready :  that in  the jelly unaltered.

   In 96 hours—the portion of muscle in the abscess
weighed twenty-five grains:  that in the matter was 
          ON THE PROPERTIES OF  PUS.        3j

dissolved:  that  in  the jelly  weighed  thirty-six
grains.

  In 120 hours—the portion of muscle in the ab-
scess weighed twenty-two grains,  not at all putrid :
that in the jelly thirty-four grains, not at all putrid.

  In 144 hours—the portion of muscle  in the ab-
scess  weighed  twenty-two  grains, and was free
from  putrefaction:  that in  the  jelly thirty-four
grains.

  The next day the jelly had evaporated to dryness,
which put an end to the comparative experiment.
The portion of muscle in the abscess was kept there
a few days longer, without  undergoing any change
or diminution of weight; and was  taken out in con-
sequence of the arm requiring fomentation, which
interfered with the experiment.
             EXPERIMENT  II.

  A similar experiment was made upon the matter
contained in an abscess recently opened, where the
Pus was  not pure, but mixed with blood from the 
 36        ON THE PROPERTIES  OF PUS.
 cut edges of the external opening, which had not
 come to suppuration.

   A portion of recent muscle, weighing one drachm,
 was  immersed in the abscess; and a similar  por-
 tion  in a small vessel of water, of nearly the  tem-
 perature of the human body.

   In 24 hours—the portion of muscle  in the ab-
 scess weighed twenty-four grains, and was  very
 putrid : that in the water  forty grains,  rendered
 smaller, but free from putrefaction.

   In 48 hours—the portion of muscle in the abscess
 was  wholly  dissolved : that in the water weighed
 thirty-eight grains.

   This circumstance alone of Pus, when in a pure
 state, not  readily taking on the putrefactive fermen-
 tation, distinguishes it from those fluids which are
 not perfect, but a mixture, which Pus must be  rec-
 koned, in these instances,  where  it has extraneous
 parts mixed with it; and  likewise distinguishes it
 from the produce of fermentation of animal or ve-
getable substances, as they run very readily through
all the different stages of fermentation,  that process
being once begun. 
ON THE  PROPERTIES OF  PUS.        3T
  The property which characterizes Pus, and dis-
tinguishes  it from most other substances, is, its
being composed of globules. This appears to throw
considerable  light upon the subject; since the pre-
sence of the globules seems to depend upon the Pus
being in a perfect state ; from which we learn the cir-
cumstances necessary for the  production of good
Pus.   Mr. Hunter was,  I believe,  the first  who
pointed out this property as a distinguishing mark
between Pus and animal  Mucus.*  For the ap-
pearance of what is commonly termed Mucus, that
is, animal substance dissolved from putrefaction, is
flaky,  and very different from Pus.  It is also by
this  property distinguished from all the chemical
combinations of animal substance that we are ac-
quainted with ;  every one of which appears in the
microscope to be made up of flakes.

  At the same time that this appearance in the  mi-
croscope distinguishes  Pus  from other substances,
It shows its great  affinity to the  animal  secretions,

  * Morgagni quotes Senac as asserting1 that the globules in
the matter of gonorrhoea are much larger than those of com-
mon Pus, which are small and unequal.  The edition of Senac
in which this is mentioned  I have not seen, but in the later
ones  it is omitted, and very properly, as it  was  evidently er-
roneous.
                        D 
 W       ON THE PROPERTIES OF  PUS.

•although  in  many circumstances it  differs  from
them.

  It differs from the blood in the colour of the glo-
bules ; in their not  being soluble in water, which
those of the blood are;  and from the fluid in which
they swim being coagulable by a solution of sal am-
moniac, which serum is not.
             EXPERIMENT  III.

   A drop of matter, and a drop of blood, were
 placed upon a piece of glass, at a small distance
 from each other, and the glass was fixed  under the
 magnifying lens of a microscope: while in this situa-
 tion, the point of a toothpick was dipped in a satu-
 rated solution of sal ammoniac, and applied to each
 of them.  This was repeated two or three times.
 The drop of matter, instead of appearing more di-
 luted, became viscid and ropy j and upon being ex-
 amined through the magnifying  glass, the globules
appeared perfectly distinct in the coagulum.

   The drop of blood had no appearance of coagula-
tion 5 oa the contrary, it was more diluted. 
ON THE PROPERTIES OF PUS.
39
   This experiment was repeated several times, and ,
 the results were always similar.

   Pus differs from chyle,  in  its globules being
 larger ; not coagulating by exposure to the air, nor
 by heat, which those of chyle do.

   The pancreatic juice  contains globules; but they
 are much smaller than those of Pus.

   Milk is composed of globules, nearly of the same
 size as those of Pus ; but much more numerous-.
 Milk coagulates by runnet; which Pus does not;
 and contains oil  and sugar, which are not to be dis-
 covered in Pus.

   The cases in which Pus is formed are, properly
 speaking,  all reducible to one, which is, the state of
 parts consequent to inflammation. For, as far as we
 yet know, Pus has, in no instance, been met with,
unless preceded  by inflammation ; and  although in
some cases a fluid has been formed, independent of
preceding inflammation,  it differs from Pus in many
of its properties,  as  has been already observed.

   In  inflammation, the smaller blood-vessels  be-
come considerably enlarged ;  and, what is curious,
this takes  place in the greatest degree in the veins ; 
 40       ON  THE PROPERTIES  OF PUS.

 the small vessels are not only enlarged, but become
 more numerous; which  does  not proceed entirely
 from the blood being propelled  further than usual
 in the old vessels, but from new ones being formed j
 and this takes place in  a much  shorter time than
 has been commonly imagined.   It is highly proba-
 ble, that these new vessels are so constructed, as to
 make the blood undergo certain changes, by which
 the fluid, that afterwards constitutes Pus, is formed.

   It has been long  ascertained, that  new vessels
 are generated in extravasated coagula of blood, and
 exudations of coagulating  lymph.  The following
 case ascertains the  period  in which  this effect can
 be produced, to be within twenty-four hours.  And
 we know that  Pus commonly  requires a  much
 longer time  for  its  formation  under the same  cir-
 cumstances, and in similar  parts.

  I performed  the operation  for the  strangulated
 hernia,  upon a man, in other respects  in health, at
 seven o'clock  in the  morning.   The  hernial sac
 was laid open,  and the  gut, which proved to be a
portion ©f the ilium, about six inches in length, was
attentively examined previous  to its being returned
into the cavity of the belly:  it had the natural polish-
ed surface peculiar  to an intestine j and  although
its vessels were tur^d with blood, it did not appear 
           ON THE PROPERTIES OF  PUS.        41

 that they were uncommonly numerous.  After the
 operation, the symptoms did not abate  so much as
 might have been expected; and, during the after-
 noon, he complained of pain  in the lower  part of
 his belly: he had no passage by stool; and next
 morning, about seven o'clock, his pulse was  scarce-
 ly perceptible to the touch ;  his skin cold and clam-
 my ;  and about twelve at noon he died, having lived
 twenty-nine hours after the  operation.

   The body was opened, and the portion  of gut
 which had been strangulated  was found considera-
 bly inflamed ; the external  surface having lost its
 natural polish, and having several small portions of
 exuded  coagulating lymph adhering to it.   The
 vessels  of the gut were minutely injected, the arte-
 ries  with a red coloured injection^  and the veins
 with  a yellow one.  Upon examination, afterwards,
 all these  adhering portions of  coagulating lymph
 were  found to be injected, having a considerable.ar-
tery going to each of  them, and a returning vein,
 which was larger than the  artery.   It  is evident,
 therefore, that the coagulating  lymph was laid upon
 the external surface of the gut after  the operation:
 and we cannot suppose, that  any such process as the
forming of new vessels  could have  been going on
during the last five hours of his life, when the pulse
in the wrist was scarcely to be  felt, and the powers
                      D 2 
 42        ON THE PROPERTIES OF  PUS.

 of life were so much weakened in every respect.
 We must therefore conclude, that the whole opera-
 tion of throwing out coagulating lymph, and  sup-
 plying it with blood vessels after it had become solid,  .
 was effected in less than twenty-four hours.

   This shows,  that  inflammation  forms a vascular
 surface previous to  the  formation of Pus.   Is it
 not, therefore, highly probable,  that the newly for-
 med parts are so organized as to secrete that fluid.

   In considering the time required  for the forma-
 tion of Pus, it is  necessary  to take notice of the
 periods which are found, under different circum-
 stances, to  intervene between a healthy or natural
state of the parts, and  the presence of that fluid,
 after the application of  some  irritating substance
 to the skin.

   In cases of wounds made  into muscular  parts,
 where blood vessels are divided, the first process
 which  takes, is the extravasation of red blood ;  the
second, is  the  exudation  of coagulating lymph,
which  afterwards becomes vascular j  and the third,
the formation of matter, which last does not, in
 common, take place in  less  than two days :  the
precise time will, however, vary  exceedingly,  ac- 
ON THE PROPERTIES OF PUS.        43
cording to the nafure of the constitution,  and the
state of the parts at the time.

  If an irritating substance 4s applied to a cuticu-
lar surface, upon which it raises a blister,  Pus will
be formed  in about twenty hours, as we find in the
following experiment.
              EXPERIMENT IV.

   A blistering  plaster, the  size of a  half-crown
 piece, was applied to  the pit of the  stomach of a
 healthy young man. In eight hours  a blister rose,
 which was   opened, and the contents  removed j
 they were fluid, transparent, and   coagulated by
 heat ; had no appearance  of globules  when exa-
 mined by the microscope ;  and in  every  respect
 resembled the serum  of the blood.  The cuticle
 was  not  removed; but allowed to  collapse j and
 the fluid, which was formed upon  the surface of
 the cutis, was examined from time  to time, by a
 microscope,  to detect, as accurately as  possible
 the changes  which took place.   The better to do
 this, as the quantity in the intervals stated below
must be  exceedingly small, a pieee of talc, very
thin  and transparent,  was applied   to the whole 
44        ON THE PROPERTIES OF  PUS.
 surface, and covered with  an 'adhesive  plaster ;
 and the surface of the talc, applied to the skin, was
 removed and examined by the microscope, apply-
 ing a fresh piece of talc, after  every examination,
 to  prevent any mistake which  might have arisen
 from the surface not being quite clean.

   The  fluid, was examined by  the  microscope, to
 ascertain  its appearance j but as the aqueous part
 in  which the globules of  Pus swim is  found, by
 experiment,  to coagulate, by adding to it a satura-
 ted solution of sal ammoniac, which is not the case
 with  the  serum of the blood, nor the transparent
 part of milk, this was considered  as a property
 peculiar to Pus j  and, consequently, that it would
 be  a very good test by which to ascertain the pre-
 sence of true Pus.

   In 8 hours—from the time the blister was ap^
 plied, the  fluid discharged was perfectly  transpa*
 rent,  and  did not  coagulate with the solution of
 sal ammoniac.

  In 9  hours—the discharge was less transparent;
 hut free from the appearance of globules

  In 10 hours—the discharge contained globules,
which were very small, and few in number. 
          ON THE  PROPERTIES OF PUS.       45
   In  11  hours—the globules  were  numerous ;
but still the fluid did not coagulate  with the so-
lution of  sal ammoniac.

   In 12 hours—the appearance much the same  as
before.

   In 14 hours—the globules a little larger ; and the
fluid appeared to be thickened by a solution of sal
ammoniac.

   In 16 hours—the globules seemed to form them-
selves into masses j but were transparent.

   In 20 hours—the globules  were double the size
of those first observed at ten hours, and gave the
appearance of true Pus in a diluted state; the fluid
was coagulated by a solution of sal ammoniac ; the
globules, at  the same time, remaining perfectly dis-
tinct ; so that this may be considered as true Pus.

   In 22 hours—no change appeared to have taken
place.

   In 32 hours—the  fluid was considerably thicker
in consistence, the number of globules being very
much increased: but in no other respect, that could 
 46       ON THE  PROPERTIES OF  PUS.
 be observed, did it differ from that  formed twenty
 hours after the application of the blister.

   As the results of microscopical experiments have
 been found exceedingly fallacious, a prejudice has
 very naturally arisen against all experiments of this
 kind upon the secretions of the human body, from
 a supposition that they are not to be depended upon.
 But it is right that we should discriminate, and not
 condemn the use of the microscope  altogether,  be-
 cause, from ignorance of its principles, it has been
 misapplied;  since these very deceptions have been
 the means of our acquiring a more  accurate know-
 ledge of the use and application of that instrument*.

   The errors in  the use of the microscope have
 arisen from increasing the magnifying powers of the
 glasses too much, and not taking in all the circum-
 stances relating to the refraction of the rays of light;
 making no allowance for the aberration.   An  atten-
 tion to the aberration alone will  explain the differ-
 ent appearances under which the red globules of the
 blood  have been represented.  Some  have  found
 them perfect spheres ; which will always be the case
 when the glasses are perfectly adjusted,  and the ob-
ject placed at the true focal distance.  Others have
 found them  annular,  from the object being  at thc
 focal  distance of  the  rays transmitted near the cir- 
           ON THE PROPERTIES OF PUS.       <&

cumference of the magnifying glass, which are re-
fracted in a greater degree, and consequendy shorter
than the central rays.  Others again have viewed
them as flattened bodies of a circular figure, bright
in the centre,  and becoming darker towards the
edges;  which appearance arises  from  the  object
being at the focal distance of the central rays of the
magnifying glass, which will be less refracted than
those near the circumference.  Although such are
the errors which arise when microscopical researches
are pushed beyond certain bounds ; yet that the red
part of the blood is made up of globules  is a disco-
very, for which we are indebted to the microscope ;
and which seems to be as well ascertained as any
discovery in anatomy or physiology.  The appear-
ances of Pus which have been mentioned are  equal-
ly distinct, when examined on the field of a micro-
scope, as the globules of the blood ; they are visible
with a small degree of magnifying power ; and are
the same to the eyes of different persons.

  The time required to form Pus, on  a secreting
surface, appears, from the following experiments, to
be five hours. 
48       6N  THE PROPERTIES OF PUS.
             EXPERIMENT   V.

   A common bougie, four inches long, was intro-
duced  into the urethra of a healthy  young man.
The surface of the bougie was not oiled, which made
the irritation more violent, and  prevented  there
being any ambiguity in the appearance of the fluid
collected upon it.

   In I an hour—the bougie was withdrawn, and the
fluid on  its surface, examined by the microscope,
was found to contain globules that were very small,
and few in number, resembling those found under
the cuticle in the blister at ten hours.  The bougie
was again introduced.

   In 1 hour—the fluid had the same  appearance.

   In 1 hour and \—the globule* larger and  more
numerous.

   In 3 hours—the globules  more numerous.

   In 4 hours—the globules larger; but the fluid
did not coagulate with the solution of sal ammoniac. 
ON THE PROPERTIES OF PUS.       49
  In 5 hours—the globules  large and numerous :
the  fluid coagulated with the solution of  sal am-
moniac.   This was  therefore considered as true
Pus.

  To prosecute this inquiry still further, an attempt  . -
was made to ascertain the changes this fluid under-
goes from the time of its leaving  the extremities of
the vessels which form it, till it becomes that thick
fluid  we  find upon  suppurating surfaces, called
Pus.

  The experiments were made upon a healthy gra-
nulating ulcer, on the upper surface of the prepuce
of a  healthy young man, about two  inches square,
forming good Pus.
            EXPERIMENT  VI.

  The surface  of the ulcer was  exposed; wiped
dry, and a piece of talc applied upon one part of it,
leaving the rest exposed.  The surface of the talc
was almost immediately covered with a thin fluid.
This, in about three minutes was removed and ex-
amined by the microscope :  it appeared to be trans-
parent ; and although examined for some time, did
                       E 
50        ON THE  PROPERTIES OF PUS.

not change in any respect from the appearance it
at first exhibited.

  This experiment proves, that the fluid, formed
during exposure, is not Pus at the time of its for-
mation.
             EXPERIMENT  VII.

   The ulcer was wiped, and four very small pieces
of talc applied upon different parts of it; immedi-
ately afterwards the whole was covered with a plas-
ter of common cerate, spread upon lint, to  prevent
the evaporation of the flufd.

   In 5 minutes—one of  the pieces of talc  was re-
moved, and  the fluid on  its  surface examined;
which  appeared like a thin transparent jelly, divid-
ed into masses ; but in which no globules could be
distinguished.

  In 10 minutes—another piece was examined, and
the appearance was like the former, but, at the bot-
tom, a number of small  globules could be  readily
discerned. 
          ON  THE PROPERTIES OF PUS.       51

   In  15 minutes—a third  piece  was examined,
and the whole mass  appeared to be made up of
small globules ; but  these were almost transparent,
and seemed to become  more distinct and opaque
while looking  at them.

   In 20 minutes—the fourth piece was examined,
and the globules were found more numerous  and
opaque, like those of common Pus.

   From this experiment we find that Pus, at its for-
mation, does not contain globules ; but is a transpa-
rent fluid, of a consistence, in some sort, resembling
jelly,  and that the globules are formed while it lies
upon  the  surface;  requiring, in some  instances,
fifteen minutes for that purpose.

   To see how  far the formation of the globules de-
pended upon the fluid remaining in contact with the
granulations, the following comparative experiment
was macfe.
           EXPERIMENT  VIII.

  The ulcer  being exposed and wiped dry,  two
pieces of talc were applied, to different parts of its 
■>2        ON THE PROPERTIES OF  PUS.

surface, and the whole covered as  in  Experiment
VII.   In five minutes, one piece was removed, and
the transparent  fluid, mentioned above was met
with ; but no globules.  The surface of the talc, on
which the fluid lay was then covered with another
piece of talc, to prevent the fluid coming in contact
with the granulations, and it was applied again to
the ulcer.   In twenty-five minutes more, it was ex-
amined  by the microscope ; as also the fluid upon
the other piece of  talc, which had remained thirty
minutes, and, in both of them, the globules were
distinct and  very numerous; but  most so upon the
portion of talc in contact with the  ulcer.

  This proves that, after the fluid is once separated
from the vessels,  the formation  of globules  is a
change taking place within itself, independent of the
granulations which secrete it.
             EXPERIMENT   IX.

  A piece of talc was applied as before, and the
whole ulcer covered for two minutes ;  the piece of
talc was then removed and examined by the micro-
scope : at first, no globules appeared.   The exami-
nation was continued five minutes;  in  which time 
         ON  THE  PROPERTIES  OF PUS.        53

the globules became exceedingly distinct to my
own eye, and to the eye of another  person  well
versed in microscopical experiments.

  This experiment was repeated several times ; but
the quantity of fluid was in general so small, that it
evaporated to  dryness before the change into  glo-
bules took place.

  From this last experiment, it is not only evident
that the formation of globules in matter is a change
that takes place in  the fluid after it is secreted; but
it further proves, that the globules are  formed in a
much shorter time when the fluid is exposed, than
when kept  from the  air.   And, we are led, from
the whole of these experiments, to conclude that the
time required for the formation of Pus, in the state
we  commonly find it  upon a healthy ulcer, varies ac-
cording to  circumstances, and is from  five minutes
to twenty.
E 2 
               CHAPTER  II.

GENERAL ORSERVATIONS ON ULCERS ON THE LEGS.


 A - HE treatment of ulcers  on the legs is by no
means confined to the practice of military hospitals;
the disease is too frequendy met with in all large
cities, and wherever a number of labouring men are
employed.   But in no situation is their treatment,
as a general practice, an object of so much impor-
tance as in the army; where the disease not only
brings distress upon the individuals, but deprives
the public service of a greater number of men than
the country, in time of war, is able to afford.

   The frequency of this disease, with which all our
public hospitals are  crowded, gives the surgeons be-
longing to these institutions ample opportunities of
seeing such ulcers in all their  different  states ; of
considering their nature, of comparing the effects of
different modes of treatment,  and of ascertaining, by
experimental inquiry, what are the speediest as well
as the best means of effecting a cure. 
        GENERAL OBSERVATIONS, &C.         &5

  To this inquiry I was led at a very early  period,
both by the precept  and example of the late Mr.
Hunter, whose active mind was  always aiming at
the improvement of his profession ; and the public
situations in which I have been placed during the
last twenty-two  years, both  abroad and at  home,
have afforded me opportunities of making a great
variety of observations.

   Ulcers on the legs have naturally  attracted the
attention of surgeons in all  ages, and many very
valuable works have been written  on the  treatment
of them.  On a  careful examination of these pro-
ductions, it will be found that this branch of surgery
has  been  progressively improving,  along  with
anatomy, and the knowledge of the animal (econo-
my ; and we must  consider that  it is, as well as
them, still capable of further improvement.   These
ulcers are to be regarded as a distinct consideration
from those which occur in the  other parts of the
body; since they vary  among themselves in a much
greater degree.   This  may be considered as arising
from the following causes.

   The legs, by their situation, are more remote
from the source of  the circulation than the  other
parts of the body, and are  therefore less perfectly
supplied with pure blood.  In many, and those the 
56        GENERAL  OBSERVATIONS ON
 most  usual positions of  these limbs,  the  blood,
 in its return to the heart, is obliged to ascend against
 its own gravity, which  retards its  progress ; and
 thus the smaller vessels are kept  in a state  of too
 great distension and resistance from the pressure of
 this column of blood.

   From these circumstances it must  appear,  that
 the legs even in health  are weaker  in their  vital
 powers than the rest of the body ; and when, from
 previous accident or  disease, new parts are to be
 formed, the  actions  in  the smaller   arteries, by
 which  this should be  effected, are impeded  by the
 languid  state of the  circulation in the veins  of> the
 limb,  whenever the  body is put into  an  erect
 posture.  If, on the  other hand,  to  obviate  this
 disadvantage, the body  be kept for any  length of
 time in a recumbent position, this is found so in-
jurious to the general  health, as in  that way to
 interfere with the production of healthy granulations.

  This deficiency of vital powers in the legs, when
compared with the rest of the body, occasions them
to be  more  readily affected  by every  thing  that
weakens or disturbs the  constitution ; and when in
 a diseased  state, the symptoms will  of  course
be influenced by the natural  or acquired peculiari- 
*.ULCERS ON  THE  LEGS.           57
 ties, as well as by the actual state of the constitution,
 with respect to strength or weakness.

    As no two constitutions are exactly similar, so it
 happens, that an ulcer on the leg has  not in  any
 two  persons exacdy the same character; for what-
 ever general resemblance one may have to another,
 there will be found also some peculiarities by which
 they may  be distinguished.  It is  therefore not
 sufficient for  the  cure of such ulcers,  that  the
 surgeon  should  be  acquainted with the general
 treatment;  a  knowledge  of these  distinguishing
 peculiarities, and their probable  causes, is also
 necessary to enable him to treat with success the
 cases of those individuals  who may be entrusted to
 his care.

   As it is  the  influence,  which the state  of the
 general  system has  upon  ulcers on the legs, that
 gives to them a variety of dispositions, it does not
 unfrequently happen that such ulcers on the  same
 person  shall at  different times, from the changes
 which have  taken place in the constitution,  require
 very  different modes  of treatment.

  From these observations it must appear obvious,
that there is no  probability that any  one medicine
can ever be discovered, which, whether internallv 
 58        GENERAL  OBSERVATIONS  0*

 administered, or locally applied, shall have powers
 adapted to the cure of all ulcers on the legs; and
 it would appear, the  idea that such  a medicine
 may  exist, has retarded  very considerably,  the
 advancement of our knowledge in the treatment of
 ulcers, by  inducing surgeons to  make use of the
 same applications, to ulcers very  different in their
 kinds.

   As no general  medicine therefore can  be ap-
 plicable  to all  ulcers,  our  study  should  be to
 ascertain the real powers of those  medicines  we
 already possess, and  to discriminate the different
 kinds  of ulcers  to which they are  respectively
adapted.

  While the doctrine of the humours was in general
 repute,  internal medicines  were  supposed  to be
 capable of removing  almost every  disease,  and,
 among the  rest, ulcers on the legs ; but practice did
not confirm this  theory ; and external applications
were of necessity  employed, before the cure could
in many cases be effected.

  When, from the advancement of our knowledge
 of the animal  oeconomy, it  was  ascertained that
 every part of the body has  actions  going on  within
 itself for its  own  increase, for repairing the waste 
            ULCERS ON THE LEGS.            59

naturally taking place, and restoring parts that have
been destroyed ; and that these actions in the dif-
ferent parts can be influenced by stimuli, locally ap-
plied, both more immediately and more efficaciously
than through the medium of the constitution,' local
applications to  ulcers were naturally preferred to
internal medicine ;  and experience has sanctioned
this preference.

   The number of external applications recommend-
ed for the cure of ulcers on the legs, is very great;
many  of  these have, by their effects, established a
reputation beyond all dispute, and  are in very gene-
ral use.   Others are of a more doubtful  character,
their healing powers resting upon  hypothetical rea-
soning, derived from their effects upon dead animal
matter, as being dryers, and by that means, causing
parts to skin over; effects which do take place un-
der their  use, but do so equally soon under the use
of other  medicines, which are known to have no
such properties.

   It has been a question',  whether all ulcers on the
legs ought to  be healed,  even  when we have the
power of doing it.  If this question is examined on-
ly so far as respects the origin of the ulcer, it is ve-
ry readily answered; for  if the ulcer is a breach in
the sohds  in consequence of an accident, there can 
60        GENERAL  OBSERVATIONS  ON
  be no doubt that the breach should be repaired, and
  the parts reinstated as soon as possible ; and if the
  ulcer arises from disease, there can be as little doubt
  that the disease should be cured.  But this question
  has been considered in  another  point of view;  it
  has been supposed that an ulcer once formed, has a
  power of drawing off, from the general system, im-
  purities which do not  find a ready  passage  by the
  natural oudets of the body ; and therefore, although
 the body went on very well before such an ulcer was
 formed, when once this new channel is opened, and
 the impurities of the blood have taken that course,
 if it be suddenly stopped, they may not readily go
 off with the natural  excretions ; and by being  con-
 fined, may do a great deal of harm.

   This theory is very plausible, and while the doc-
 trine of the humours was generally believed, must
 have been unanswerable.   But if the production of
 Pus be an action of  the parts surrounding the ulcer
 for their own recovery ; if it be independent  of the
 general system,  otherwise than as it  occasions a
 greater supply of blood than usual, to be sent to that
part, then this theory must fall to the ground.

  From  these observations it appears, that the  dif-
ferent kinds of ulcers on the  legs, may be safely
healed, there being no  chance of  any  thing  being 
ULCERS ON  THE  LEGS.
61
thrown back, upon the general system,  or retained
there, in consequence of their cure.

  There are circumstances, however, in which it
would be improper to heal an ulcer on the leg ;  but
these are totally independent of the theory I have
endeavoured to refute.

  If a  patient of a gouty habit has an ulcer on the
leg, which is evidently affected by the gout, having
regular attacks of pain returning at  stated periods,
and those attacks  similar to what the same person
had experienced from gout in other parts ; under
such circumstances, any attempt to heal the ulcer is
improper;  for if it should be  attended with  suc-
cess, the gout may fall upon some more important
part.

  There are many constitutional irritations, equally
unintelligible with the gout, which occasionally fall
upon the weakest or most irritable parts of the body.
If it is found that an ulcer upon the leg breaks out
whenever the constitution is disturbed, and if, when
that happens, no other part  is affected, it would be
imprudent to heal that ulcer.   Many people are af-
fected in the spring by head-aches, ulcers on the
throat,  pains  in the chest,  eruptions on the  skin,
which ever is the  weakest or  most irritable part in
                        F 
62         GENERAL OBSERVATIONS  ON

the individual who is liable to such attacks ; if any
such person should have an ulcer on the leg, and the
constitutional  affection, whatever it may be, should
fall upon the leg, now rendered more susceptible  of
such  attack than  any  other part of the body, it
would be imprudent to interfere, or attempt to heal
that ulcer.

  That the periodical attacks just stated, with which
every one must be perfectly acquainted, are consti-
tutional affections  falling upon particular parts, and
not really a disease in the parts themselves, will  be
illustrated  by the  following instance; and, were it
necessary, a great many others might be given.

  A gentleman, who for many  years was subject
every spring to violent attacks upon his chest, had
a disease which took place in the bladder, of a very
distressing kind.  As soon as that viscus became the
weakest and most irritable part of the body, he lost
entirely the periodical  returns of the complaint  in
the chest; they fell upon the bladder ; so that, inde-
pendent of the constant symptoms peculiar to the
complaint, he had regular  attacks, at intervals  of
some months,  of the most violent irritation in that
viscus. 
ULCERS ON THE LEGS.           63
  When any ulcer has existed on the leg for a great
many years, it becomes an habitual disease, difficult-
ly removed, and when it has been healed breaks out
again ; the parts readily falling back into a state to
which they had been long accustomed.  There is,
however, no reason why the ulcer, under  these cir-
cumstances, should not be removed, unless the pa-
tient be very infirm or old.

   At a late period  of life it is imprudent to make
the smallest change  in  the oeconomy  of the  body,
even in those respects which may appear  to  its ad-
vantage ;  for the smallest disturbance sometimes
proves  fatal.

   If, in a weak state of body,  a copious evacuation
by  stool has been immediately followed by death ;
if the drawing off the water by the catheter, when it
has been too long retained, has had  a similar con-
sequence in the  course of a  few hours; both of
which events I have witnessed; it shews that the ac-
tions of the vital organs cannot go on under such
circumstances, if the smallest violence be committed
uppn any part of  the machine, even where it is not
attended with any loss to the general system; for
in both the cases  which have  been mentioned, the
contents that were evacuated must have been some 
(BENERAL  OBSERVATIONS  ON
time separated from the system, and deposited  in
their proper reservoirs.

  The removal of any habitual irritation, in such a
state of body, may be productive of harm.  A per-
son long accustomed to drink a dram in the morning,
on leaving it off, has lost his health j the irritation of
an ulcer  may have an effect  upon the general sys-
tem, of which it will be dangerous to deprive it. The
healing of an ulcer on the leg, as it prevents so much
blood from being carried to that part, for the forma-
tion of Pus, may, when the machine is falling into
decay, increase the quantity carried to the vessels of
the brain, and produce apoplexy, by causing some
t>f them to be ruptured.

   There  is a curious effect of approaching death,
which has been sometimes improperly attributed to
the treatment of the surgeon.  An ulcer of twenty
years standing sometimes heals up of itself in the
course of a few days,  and the patient dies some
hours  after, or at least in a very short time.   This
circumstance, of the healing  of the ulcer, appears
to be an effect of that change which the general sys-
tem frequendy undergoes previous to its dissolution,
and corresponds with the sensation of unusual health,
often experienced immediately before a severe ill-
ness, and also immediately before death. 
ULCERS ON THE LEGS.
65
  GENERAL DISTRIBUTION OF ULCERS INTO THEIR
                     SPECIES.

   To render the medicines we employ as generally
useful as possible, it appears a very desirable object
to distinguish the various ulcers on the legs, occur-
ring in practice, into different kinds, as far as we are
enabled so to do upon general principles ; and then
to state the particular remedies which more properly
belong to each of these classes.

   If a plan of this kind can be carried into effect,
which is the object of the following observations,  a
surgeon, as soon as the nature of an ulcer shall be
ascertained, will very much have circumscribed his
subsequent labours; since he will only have to dis-
cover, by trials, which of the medicines found most
applicable  to that species of ulcer will best agree
with the particular case under consideration.

   A knowledge of all the medicines fitted  for each
species of ulcer will also be  attended with  another
advantage; for it will be found, as will be hereafter
more fully explained, that the  same  application,
however it may agree at first, will,  if used  beyond
a certain time, lose its good  effects,  and therefore 
66        GENERAL OBSERVATIONS  ON
will require to be changed for some other of similar
powers.

   From all the consideration that I have been able
to bestow  upon the subject, and  my opportunities
have been  very extensive, I am led to believe, that
ulcers on the legs differ from one another according
to the following circumstances : local peculiarities,
constitutional peculiarities, peculiar  dispositions of
the parts or of the constitution, and diseased dispo-
sitions of the parts or of the constitution.   I have
therefore  divided them  into  six different  species,
each  of which requires a very distinct and different
mode of treatment.

   1.  Ulcers in parts that have sufficient strength to
carry on the actions necessary for their recovery.

   2.  Ulcers in parts that are too weak for that pur-
pose.

   3.  Ulcers in parts whose actions  are too violent
to form healthy  granulations, whether this arises
from the state of the parts or  of the constitution.

   4.  Ulcers in parts whose actions are too indolent,
whether this arises from the state of the parts or of
the constitution. 
ULCERS ON  THE LEGS.
67
  5. Ulcers in parts which have acquired some spe-
cific action, either from a diseased state of the parts
or of the constitution.

  6. Ulcers in parts which are prevented from heal-
ing by a varicose state  of the superficial veins of
the upper part of the limb.

  These six species of ulcers are to  be considered
separately;  and in stating the different applications
suited to  each species,  they  will be noticed, where
they admit of it, under four different forms ; for the
same  form of medicine does not always answer in
different cases of the same species of ulcer, to which
the virtues of that medicine may be generally appli-
cable. In one case, the medicine  shall agree best in
the state of vapour ;  in another, in a fluid state ; in
others, in the form of ointment; and in others again,
in the form of powder. 
CHAPTER   III.
  OF ULCERS IN PARTS WHICH HAVE SUFFICIENT
   STRENGTH TO CARRY ON THE ACTIONS  NE
   CESSARY FOR THEIR OWN RECOVERY


 W HEN an accident happens to the leg  of a per-
son in perfect health, by which a portion of the skin
and muscles is deadened, or only simply divided, if
they are not united by the first intention, an ulcer is
the consequence.  Such an ulcer requires no medi-
cated applications for its cure, the parts having suf-
ficient powers within themselves to  restore the lost
muscles, cellular membrane,  and skin, by the pro-
cesses of inflammation, suppuration, granulation, and
cicatrization; these being the means  instituted  by
nature for the restoration of parts.

  In this species of ulcers the matter or pus, which,
is formed  in the  stage of suppuration,  is  white,
thick, readily separates from the  surface  of the
ulcer,  and when diluted,  and  examined  in  a
microscope, is  found  to  be  made up of small 
           ULCERS ON  THE  LEGS, &C         69

globules swimming in a  transparent fluid.   The
granulations are small, florid, and pointed at the
top ; as soon as they have risen to the level of the
surrounding skin,  those  next the old skin  become
smooth, and are covered with a thin, semi-transpa-
rent film,  which  afterwards becomes opake, and
forms cuticle.

   All that is required in  the treatment of  such an
ulcer is, to keep the surface  clean, and prevent the
natural processes from being interrupted in  the
course of the cure; this  is,  in general, best done
by the application of dry lint, to absorb  and retain
the matter, which serves  as  a soft covering for the
granulations, that appears necessary to  preserve
them in a healthy state, and a pledget of any simple
ointment over the whole,  to  prevent evaporation of
the matter, that the dressings may be readily, and,
at proper intervals,  removed.

   This  mode  of treatment, were it not  for the
peculiarities of the constitutions of different patients,
would  apply equally to all ulcers of this  species;
but these pesuliarities are so various as to require
particular consideration.

   Although  healthy  ulcers require no  medicated
application  to  be made to them  in any case,  it is 
70
OF ULCERS IN PARTS.
necessary that the dressing should  be of  a kind
that does  not disagree with the granulations, or
surrounding skin, since if it does so, in the slightest
degree, the progress of the cure will  be retarded.

   By  some  patients  a roller  applied moderately
tight, to secure the  dressings, will be  found so
uneasy to the parts, as to make the  ulcer lose its
healthy  appearance,  which will  be resumed  on
leaving off the bandage.  Several  cases of this kind
have fallen under my care.

   In some instances the application of ointment will
disagree even with  the neighbouring, skin.   In
others, when superficial, the ulcer will not skin over
while the surface is kept moist,  and confined from
the air ; but if exposed, and allowed to scab, it will
heal.

   That the modes of  treatment which most com-
monly answer, and consequendy ought  to be in ge-
neral use, prove hurtful in particular cases, must be
referred to the constitution, which has its  influence
over every component part of the body.  They are
entirely unconnected  with disease; for as soon as
the offending application is removed, the ulcer con-
tinues its progress towards a cure.  These peculiari-
ties are deserving of particular notice, since they are 
        WHOSE ACTIONS ARE HEALTHY.       71

equally liable to occur in the other species of ulcers
which  we are about to consider,  as in these of the
healthy kind;  and if not  sufficiently  attended to,
may be mistaken for the effects of diseases, and may
lead to very improper modes of treatment.

   As in the management of ulcers of this species the
great object is a knowledge of the peculiarities of the
constitution, if there are any, an inquiry should be
instituted into the effects of different applications to
the same person upon  former occasions;  whether
 oily or watery substances agreed  best with the skin;
 whether exposure to the air disposed former ulcers to
 form scabs, or the reverse ;  and if scabs were formed,
 whether the parts underneath skinned over or not.
 From such questions a surgeon will in general pro-
cure material information,  and frequently be led at
once to the most judicious mode of practice ; while,
on the contrary, a want of attention  to these cir-
cumstances may be the cause of protracting the cure
for a considerable time. The truth of this obser-
vation cannot be better illustrated, than by mention-
ing the following circumstance.   A boy at school,
by some  accident, had several small ulcers on his
leg, on which account  he was  immediately  sent
home.   As he was the son of a nobleman of high
 rank, every attention was paid to them, all kinds of
 dressings were tried, but without the desired effect.
 Under these  circumstances, it was proposed (as 
72
OF ULCERS IN  PARTS
there was nothing in the appearance of the ulcers to
account for their backwardness in heahng) to leave
off all dressings, and make him wear a pair of loose
trowsers, night and day, to prevent any thing from
adhering to their surface : under this mode of treat-
ment they readily healed.
APPLICATIONS CONSIDERED, WITH REFERENCE TO
             THIS SPECIES OF ULCER.

   1. In the form of vapour.

   Nothing should be applied in this form, although
it  is sometimes done by way of fomentation.   The
effect, however, is  pernicious, since the granulations
are thereby rendered looser in  their texture, and
less disposed to form skin.

   2. In a fluid form, or moist state.

   Poultices are not less improper than fomentations.
Alcohol diluted in different proportions is found, in
many instances, to dispose the granulations,  when
upon a level with the neighbouring skin, to form a
scab.   When that  object is desirable, this  method
will answer the purpose. 
       WHOSE ACTIONS ARE HEALTHY.       73

  3. In the form of ointment.

  Ointments are seldom employed in this species of
ulcer with any other view  than to prevent evapora-
tion, and are not usually in contact with the granu-
lations ; for this purpose the simplest forms appear
to be the best,  as that made of equal parts of white
wax and olive  oil; the ceratum epuloticum is sup-
posed, from the lapis calaminaris which it contains,
to assist or hasten the formation of new skin.  No-
thing has  occurred  within my own experiment,
which at all tends to favour this opinion.

  The great objection to the common  simple  oint-
ments—as cerate, and others of that kind, is, that
they sometimes disagree with the skin, even when
recently  made, and in the most perfect state ; but
when allowed to become rancid, which they do by
being  long  kept, they  too often irritate to a very
considerable degree,  and  aggravate the symptoms
they were meant to relieve.

  As  the  army surgeons  are supplied with oint-
ments  only once a year, or once in  two years, and
these ointments,  from  being made in very  large
quantities,  are more liable to suffer  in the making,
by the heat employed rendering the oil empeure-
matic; it would be a much better plan to give an
                       G 
74
OF ULCERS IN  PARTS
 allowance of white wax and olive oil to each regi-
 mental surgeon, who could make them into oint-
 ment in small quantities, as he had occasion, so as
 always to have it in a recent state.

   In the West Indies, during the last war, oint-
 ments were supplied very liberally by government;
 but in that country the heat rendered them so ran-
 cid, that they became very stimulating applications,
 and only adapted to ulcers of an indolent nature.

   4.  In form of powder, or in a dry state.

   If it be thought advisable to form a scab upon
 the surface of the ulcer, this may be soon effected,
 by applying a small quantity of any inert substance
 in form of powder;  but, as dry lint will answer the
 purpose, I should for many reasons prefer it.

   When either of these  means are  employed,  no-
 thing should be allowed to come in contact with the
 powder or lint applied to the ulcer.   This is best
prevented by putting a  small bolster of linen  on
 each side of the ulcer, and over these a bandage, so
that the bandage may form a kind of bridge over
it, and be kept at some distance, while it  defends
the surface from any accidental violence. 
        WHOSE  ACTIONS  ARE  HEALTHY.       75

  Dry lint is the common dressing in use, and, as a
general practice, is the best.  When the ulcer does
not form a sufficient quantity of Pus completely to
to moisten the lint in  twenty-four hours, the dress-
ings  should only be  changed  every other day, as
the removal of the lint when it  adheres, even slight-
ly, disturbs the formation of new skin, and makes
the granulations afterwards less  disposed to form
it.

   A bandage applied tolerably tight, where there is
no  peculiarity in the  constitution to forbid  its use,
gives a firm support to the muscles and skin, which
are frequently loose and flabby  from the want of the
natural healthy movements  of the limb.  It  is also
a defence to the newly formed parts. 
CHAPTER   IV.
 OF ULCERS IN  PARTS  THAT ARE  TOO WEAK TO
   CARRY ON THE ACTIONS NECESSARY FOR THEIR
   RECOVERY.


 U LCERS of this kind differ from those in healthy
 parts; the granulations are largo: in size, rounded
 upon their external surface, less compact in their
 texture,  and semi-transparent.   When they arrive
 at the surface of the body, they do not readily form
 skin, and  frequendy  continue  to rise still higher,
 and then entirely lose the disposition to form  new
 skin.  In a still more weakened state of  parts, the
 granulations, after having gone  on favourably for
 several days, shall all at once give way, and be ab-
 sorbed into the constitution,  leaving the ulcer as
 broad  and deep as it was before, the granulations
 not being  strong enough to preserve themselves
 from decay.

  Ulcers may from the beginning exhibit these ap-
pearances of want of strength in the newly formed 
OF ULCERS  IN PARTS, &C.          77
parts; or they may at first go on for a few days in
every  respect  like those  in healthy parts, but be-
come unable to do  so beyond that  period, and the
granulations then show signs of weakness.   For
granulations of the most healthy kind,  if they are
not  skinned over in a certain time, 'appear to lose
their original strength, and fall into a weak state.

   Ulcers on the legs have been already stated to be
influenced,  in a very considerable degree, by the
natural peculiarities of the  constitution ; they are
found to be still  more so by any thing that affects,
in the  slightest manner, the patient's general health.
The appearance  of the granulations  undergoes a
change, upon the least  diminution  of constitutional
strength ; and if that be restored,  the granulations
return to their former state ;  so that an ulcer of a
healthy, kind  becomes in general  a very accurate
index  of the strength or  weakness of the constitu-
tion.

   The influence produced upon ulcers by any dimi-
nution of the constitutional strength is  the greater,
the further  the seat of the ulcer is removed from
the source of the circulation.  If a person in a weak
state has two ulcers on the same leg, one near the
knee,  the other near the ankle, as  he recovers his
strength the two ulcers will assume  a more favoura-
                       G 2 
78        OF ULCERS  IN PARTS WHOSE
ble appearance ;  but the effect will  not be  equal in
both;  that  nearest the  knee will  show the  first
signs of amendment,  and will go on healing faster
than the other.   This may by many be considered
as accidental, but the instances  of  it which occur,
appear to be'sufficiently numerous to prove that it
arises from some general principle.

   Whatever disturbs the constitution seems to pro-
duce a temporary imperfection in the actions of the
animal  ceconomy ; for while the body is in that state,
the progress of healing in an ulcer appears to be at
a stand.  We see this effect produced occasionally
by anxiety of mind.  A small ulcer, which the pa-
tient is  led to  suspect may be venereal, will some-
 times remain, without making the smallest progress
towards a cure, during  fourteen  days, in  conse-
quence of a state of anxiety brought on by this sus-
picion :  but the moment the mind is at ease, the
ulcer will begin to heal, and get well in a few days.

   These effects upon ulcers, produced by the state
of the constitution, are greater in weak and delicate
people, than in  the strong and  robust.  They seem
 to take place in  the greatest degree in those consti-
 tutions, which,  from the effects ofparticular modes
 of life, and the  influence of different climates, are
 very susceptible of impressions.  The following ob- 
POWERS ARE TOO WEAK.          79
servation offers a confirmation of this opinion.  In
the year 1778,  after the naval  action between the
English and French, the wounded seamen, belong-
ing to admiral Keppel's fleet, were all carried into
the Naval Hospital at Plymouth : among them were
several hundred patients  with  ulcers, from acci-
dents on board of ship, and most of them on the
legs.   Wheaever there was any violent <l: 1 sudden
change in the weather, from a dry to a moist state,
which is very often the case  in  October  and No-
vember, on that part of the coast, it  had an imme-
diate effect upon all the ulcers in the  hospital; giv-
ing  them  universally  an  unhealthy  appearance.
Instead of Pus, the granulations threw out an exu-
dation of coagulating lymph,  which lay upon  the
surface of the ulcers, looking exactly like melted
tallow ; and when the weather changed again, and
became dry, they  put on  a more healthy appear-
ance.

   For the  cure  of this species of ulcer it is neces-
sary to pay attention to the constitution ;  such me-
dicines  as strengthen are to be employed, as bark,
and steel; and whatever is found to  affect the con-
stitution unfavourably is to be avoided as much as
possible.  By these means the local  treatment will
be materially  assisted.  In this  languid  state it is
common to give wine and cordial medicines ;  but 
 80       OF ULCERS  IN PARTS WHOSE

 the treatment of any set of men should be adapted
 to their modes of life;  and with soldiers, and in-
 deed the whole class of working people, porter is of
 much more service  than wine; it does not heat so
 much, and they in general like  it much better.  In
 the present war, the hospitals under Sir John Mac-
 namara Hayes were liberally supplied with porter,
 and the men recovered their health very  fast under
 its use.

   The  first object,  with respect to  the ulcers
 themselves,  is to prevent the  granulations  from
 rising higher than the edge of the surrounding skin,
 since it is a fact well established,  that when they
 are higher than the level, they are  not disposed to
 form  skin.  This is  not sufficiently attended to
 in common practice  ; but another mode is adopted,
 which is erroneously supposed to produce the same
 effect.  Escharotic medicines are used to eat down
 the granulations, whenever they are  found to be too
 high, and in this way  they are  reduced  nearly  to
 the  proper level.  There can be no doubt, that if,
 by any means, the granulations  could be prevented
 from rising  beyond the surface, it would  save a
 great deal of pain to the patient, and be attended
with other advantages ;  and this may be done, as
will  be explained,  by   making use of  dressings
adapted for that purpose.
I 
POWERS ARE TOO WEAK.           81
   It becomes a question, how far escharotics should
be  employed,  even  when  the  granulations,  by
inattention, have been allowed to become luxuriant;
since the very  act of destroying  the  upper part of
the granulations  seems to increase the growth of
the part that remains, so that the  disposition  for
luxuriance in the new flesh is not corrected, but
rather increased, and there is a constant  necessity
for making use of the same harsh means of keeping
them within bounds, till they shall be disposed to
form skin ; a process which would have taken place
much sooner under another  mode  of treatment.
If, on the  other hand, such medicines are used as
have a  stimulating power,  which  is proportioned
to the  strength  of the granulations, the  super-
ficial luxuriant parts, to which they are  immedi-
ately  applied,  will  be absorbed,  and those un-
derneath will be checked in their growth.  Instead,
therefore, of touching  the  surface  of such  ulcers
with the lunar caustic, blue vitriol, red precipitate,
or any other of the  escharotics in  use,  the same
medicines  compounded with  other  substances,
which will diminish their activity, and render them
only strong stimulants, may be used with advantage.

  To illustrate the  difference between the effects
of escharotics and of stimulants, in keeping down
granulations, I shall mention what happens  in the 
82
OF ULCERS  IN PARTS WHOSE
 case  of warts ; which are  only a  luxuriancy  of
 growth from the cutis, and, like granulations, and
 all other  newly-formed  parts, are weaker in their
 living principle than original parts.

   If warts are touched by escharotics, it is found
 that their growth is rather increased than  stopped
 by such treatment; and they cannot be removed
 by these means, unless the  caustic acts beyond the
 basis of the wart, and destroys a part of  the  skin
 underneath.   But if a stimulating application, such
 as the  powder of savin  mixed with aerugo aeris,  is
 employed, it excites a degree of action in the wart
 itself,  whose vital  powers are  weak, and, in con"
 sequence  of the degree of action thus produced
 being greater than the parts are  able  to sustain, the
 absorbents take them back into the circulation, and
 the wart  is wholly removed;  but if the same ap-
 plication is  made to the  common skin, it produces
 no effect at all.

   As the  great object in the healing of an ulcer is
to have the new flesh, by which it is filled up, as
strong in its living powers as possible, that it may
not afterwards break out  again, every thing  that
can conduce to that end is  deserving of attention.
 It is reasonable  to  conclude, that in  the growth of
animal substance, as of vegetables, where there is a 
POWERS  ARE  TOO WEAK.            83
rapid increase, the parts growing are  weaker than
where it is slow; and if the granulations, which are
already growing beyond their strength, have this
rapidity increased by partial removals, they must in
reality be rendered weaker than they were before.
If this reasoning be just, which there is reason to
believe it is (since  the observations on which it is
founded are taken from practice) the treatment of
granulations ought to be regarded in a point of view
that has  hitherto been  litde considered.   Their
growth ought to be kept-back in an early stage of
their formation, by such resistance as they are just
able to overcome ; which will at the same time re-
tard their increase,  and allow  them  to  acquire
strength by their own actions;  for new-formed parts
in a living body are strengthened in proportion to
the action they are obliged to exert.  This, however,
is confined within certain limits, for if the actions
are increased beyond the real strength of the parts,
the absorbents  remove them altogether,  and an  at-
tempt is made to produce a new growth of granula-
tions, strong enough to support the actions required
of them.  This they are sometimes unable  to ac-
complish, and the ulcer remains nearly  stationary,
till the stimulating application is removed.

   It is upon this principle that the pressure made by
tight bandaging is found so useful in this kind of ul- 
84
OF ULCERS  IN PARTS WHOSE
 cer; and it is from the same cause that those ulcers,
 which  heal while the patient is walking and using
 exercise, are less liable to break out again, than those
 which  are healed under the  circumstances of rest
 and perfect quietness.

   I have dwelt the longer upon the necessity of at-
 tending to the strengthening of granulations, at their
 first formation, from  finding, that after they are once
 formed they  do not appear  capable of becoming
 stronger, in the same degree;  but give way  under
 the slightest increase  of motion in the parts, even af-
 ter they have  been allowed what might be consider-
 ed a sufficient time to acquire strength, and the ul-
 cer itself has been completely  healed.   We have
 daily proofs of this weakness of  granulations, in all
 the stages of their growth, in our public hospitals.
 When a patient is  first received with an ulcer in a
 very disturbed state, from improper treatment, with-
 out any distinct appearance of granulations,  under
 the application of a  poultice the surface  will  fre-
 quently become clean, and granulations will rise up
 in every part: these will increase, and appear to be
 strong  and healthy (when superficially examined)
 while the patient remains in bed;  but as soon as he
 gets a  little  better,  and  walks about, the  ulcer
 spreads; the motion  of the limb h^ing greater than
the granulations can support, on which account they 
POWERS  ARE TOO WEAK.
85
 are absorbed, and taken back into the constitution.
 If the patient be kept in bed, the ulcer will heal, and
 he  may leave the hospital perfectly well;  but  as
 soon as he returns to his usual exercise the  granu-
 lations, too weak to support themselves,  give way,
 and the ulcer breaks out again, and becomes nearly
 of the same size as at first.

    As this  is one of the  most common species of ul-
 cer to which  soldiers are liable, it is  of the utmost
 importance that military surgeons should be made
 acquainted with the  cause why many of them are so
 liable to break out again ;  that they may avoid this
 consequence, and by their mode of treatment enable
 their patients to return to their duty as soon as pos-
 sible after  the ulcer shall be healed.

   Ulcers on the leg may be, in the first instance, of
 the truly healthy kind, but from their size the parts
 towards the centre may  be so long kept from skin-
 ning, that the granulations may become weak,  and
 when they  have arisen  to  the  surface may  remain
 stationary,  without shewing any disposition to form
 skin.  When this is  the case they generally, after a
day or  two, acquire a  fresh growth, and become
luxuriant.

  In the treatment of  such  ulcers it is  therefore
                       H 
 86         OF ULCERS IN PARTS WHOSE

proper to attend to this circumstance, and whenever
it is seen that the granulations, though come to the
proper height, do not form a thin semi-transparent
pellicle upon the surface they are to be considered
as weak parts, and treated accordingly.  The sim-
plest and best mode, where the constitution has no
peculiarity which forbids  it,  is pressure ; this may
be made by a piece of thin lead over the dressings,
and will be assisted by a tight bandage on the limb,
which by compressing the parts, makes the circula-
tion through the veins  less tardy,  than when the
parts are left to themselves.
APPLICATIONS CONSIDERED  WITH REFERENCE TO
            THIS SPECIES OF ULCER.

   It is questionable whether  we have any power of
strengthening parts by local applications ; but it is
equally questionable  whether the  constitution  can
really be made stronger by the use  of  internal me-
dicine ; since absolute strength can only be convey-
ed to the body  by means  of nutriment,  which is
not contained in  the substances  used in medicine.

  It is, however, by no means improper, in the prac-
tice of physic, to call those medicines strengthened
which, by their action on the  internal membrane of 
POWERS ARE TOO WEAK.          87
 the stomach, increase  the  secretion of the gastric
juice, so as to convert a greater proportion of the
 aliment  into chyle ;  or by their action on the ab-
 sorbents, stimulate them to take up a greater quan-
 tity of the  chyle, and convey it into the circulation:
 or which, by regulating the actions of the different
 parts of the system,  diminish the general expen-
 diture of the nourishment of  the  body : since  all
 medicines  which act in these different ways,  do"1n-
 direcdy  contribute to render the body stronger than
 it was before.

  The same observations apply, with equal propri-
 ety, to the  applications made to ulcers in weakened
parts.  Whatever prevents  the granulations from
exhausting themselves by luxuriant growth, or sti-
mulates them to draw more abundant supplies from
the arteries, does, in effect, render  them stronger.

  1. In the form of vapour.

  The fomentations  in common use to many other
species of  ulcer,  are improper in  those whose ac-
tions  are too violent for  their powers to sustain,
since the application  of heat increases the actions of
parts, gives them a greater tendency to become lux-
uriant, and renders them still weaker than they were
before.   Fomentations  sometimes  give pain when 
 88         OF ULCERS IN PARTS WHOSE

 applied to parts in a very weak state ; this happens
 when  the action  excitedVby their warmth exceeds
 what the  parts can readily perform ; and whenever
 this symptom occurs, they should be left off.

   Spirits of wine and decoction of poppies, in equal
 proportions, may be substituted with advantage for
 the common fomentations, but must not be applied
 hot.  They often soothe the sensations of the parts,
 and lessen their actions.  Where the granulations
 appear to  be disposed to run  into mortification,
 this application is sometimes the means of  prevent-
 ing it.

   2. In a watery form or moist state.

   Poultices are not adapted to this species  of ulcer,
 for the reasons already stated.
   The argentum  nitratum in weak solution in wa-
 ter,  the strength proportioned  to the state of the
 ulcer, is one  of  the best applications in a watery
 form.

   3. In the form  of  powder.

   There are several  medicines used in the form of
powder to this species of ulcer;  of these the most
common are bark, and the  lapis calaminaris: the 
           POWERS ARE TOO WEAK.           89

bark is supposed to have a power of strengthening
the granulations, and the lapis calaminaris of dis-
posing them to form skin. . I have very frequently
had recourse to both of them, but cannot, from any
experience of my own, speak in their favour ;' never
having seen the effects that are attributed to theii
sufficiently obvious to merit the character they have
acquired.  Powdered  chalk  and plaster of Paris
have been brought into notice, as disposing granula-
tions to form skin; but such a power appears to be
improperly attributed to them.

   Powdered carbon has been used with success, but
its effects  are more conspicuous  in ulcers attended
with irritability ; than those attended with weak-
ness.

   Powdered rhubarb is an application which I have
used  to different species  of ulcers, and ventured
some years ago  to  recommend it to the notice of
the public*  It appears more particularly applica-
ble to this species, having a power over the luxuri-
ant growth of granulations, rendering them small
and compact, and disposing them to form skin ; but
if they have been  permitted to  rise considerably

   * See Transactions of a Society for the Improvement of Me-
dical and Chirurgical Knowledge, vol. i,
                    H 2 
90       OF ULCERS IN PARTS WHOSE
above the proper  level,  it is not powerful enough
to lower them.

  The rhubarb is apt to form a crust upon the edges
of the ulcer, which should be occasionally removed,
to prevent the matter from being confined under it.
This should be done with care, to avoid hurting the
new skin which begins from the edges,  and to the
formation of which this crust seems to be favoura-
ble.

  If the rhubarb alone is too stimulating, which is
sometimes the case, adding one-fourth part of the
powder of crude opium, makes it a milder  applica-
tion.

  It is to be  understood, that when any of the pow-
ders above-mentioned are used, a small piece of
lint, nearly the size of the ulcer, is to be laid over
the powder, and the whole covered by a pledget of
simple ointment.

  4.  In the form of ointment.

  Unctuous  applications appear to disagree more
frequently with ulcers of this kind than any others;
and in many  instances where  they have  been long
used, the omission of them will be followed, almost 
POWERS ARE TOO WEAK.
91
 immediately,  by  a more favourable appearance.
 This I have seen so often, as to have no doubt of
 the fact, and even where the powdered lapis calami-
 naris has been supposed to be beneficial, I have been
 inclined  to suspect that it is in no other way than by
 defending the surface  of the granulations from the
 ointment, which, before the powder was  used,  had
 been more or less  in contact with them.

   Although ointments are often improper, it can-
 not  be  asserted that  they are  always so,  it  will
 therefore be right  to try them in those cases where
 a cure is not obtained  by  means of the other appli-
 cations.

  The ointment which seems  most  applicable to
 cases of  this kind, is the unguentum hydrargyri ni-
 trati, mixed with hog's lard, in the proportion of
 one to five.

  Common  cerate, with a small proportion of  the
 hydrargyrum nitratum  rubrum, is also a useful  ap-
 plication.  Both these  preparations give a check to
the luxuriant granulations, and are best adapted for
reducing them when they have risen to too great a
height. 
92        OF  ULCERS  IN  PARTS  WHOSE

  After having enumerated the various medicines
which may be used with success  in different cases
of this species of ulcer, it may be necessary to men-
tion the order in which they stand in practice; be-
ginning with those most generally useful.

  The  rhubarb seems to  agree with the greatest
number of patients, and is therefore the application
to which the first trial  should be given.  Its effects
are not to be decided upon for two or three days, as
almost  every  application appears to be  of  service
for  that length of time ; but if the ulcer goes on fa-
vourably for a week the medicine is certainly to be
continued;  if on the  other hand, after the third
day the ulcer appears to be  stationary, it is  then to
be left off.

  The argentum nitratum dissolved in water,  and
diluted  till the solution, when applied to the tip of
the tongue, feels slightly pungent,  is to be adopted
when the rhubarb does not answer; and  if this  also
disagrees, or does not produce  any amendment in
the ulcer, then the unguentum hydrargyri nitrati is
to be used;  and if still no progress is made towards
a cure, recourse may be had to the ceratum epulo-
ticum, or any other common ointment, with the hv-
drargyrum nitratum rubrum, in the proportion of
half a dram to an ounce. 
POWERS ARE TOO WEAK.         93»
   Which ever of these applications is used the ulcer
should  only be dressed  once in the twenty-four
hours, unless the quantity of discharge should prove
so great as to require  it to be done more frequent-
iy.

   When the ulcer is on the lower part of die leg,
in whatever way it is dressed, care should be taken
to support the muscles of the calf of the leg, which
in general will be found  very flaccid, and when the
leg is lifted up from the bed,  hanging loose from
the tibia.  Without  such support,  the ulcer will
frequently resist every means that is used to make
it heal.   In this state of the limb, the arteries and
veins are deprived of their lateral support, so that
the circulation through the smaller vessels, is under
circumstances unfavourable for the process of form-
ing new flesh.

  To illustrate this, it may be proper to state thei
following case.   A gentleman between sixty and
seventy years of age, who had lived freely, had an
ulcer take place a little above the  inner ankle of the
right leg; this was at first neglected, as it did not
give much pain,  but in  the course of eight  or ten
days, it began to spread so rapidly as to give alarm
to the patient, and also to the surgeon who attended
him; under these circumstances I was called in, the 
.94          OF ULCERS IN PARTS &C.
patient was taking bark and opium internally very
freely, and the ulcer was poulticed with bread and
milk.  From the appearance, I was led to consider
this  ulcer of the irritable kind, and directed some
tincture of opium to be sprinkled on the surface of
the poultice, but in two days there was no apparent
amendment.   I was therefore led to  object  to the
poultice, and thought its weight might occasion the
ulcer to spread ; the dressings were lint wetted with
a solution of extract of opium in water, covered by
an ointment of wax and oil: this in two days had in
no respect arrested the progress of the ulcer  which
was spreading rapidly. Seeing the extremely flaccid
state of the muscles, I was led to consider that alone
as the cause of the ulcer spreading, and desired the
limb to be well supported with a roller as high as
the knee,  and the same dressing continued. Under
this treatment, in two days the ulceration had stop-
ped, the granulations  had put on a healthy appear-
ance, and in  a week's time, an  ulcer three  inches
broad and five long, was  nearly skinned  over, and
in a few days  more was entirely healed. 
CHAPTER  V.
 OF ULCERS  IN  PARTS WHOSE ACTIONS ARE TOO
   VIOLENT  TO  FORM  HEALTHY  GRANULATIONS;
   WHETHER THIS ARISES FROM THE STATE OF THE
   PARTS OR OF THE CONSTITUTION.


VV hen an ulcer takes place on the  leg of a person
 of an healthy constitution, it can only be  prevented
 from healing, under proper  treatment, by the weak-
 ness of the parts;  but when the general system is
 not perfecdy in that state, whether from some natural
 peculiarity, or some accidental disturbance, this will
 operate as a cause to prevent  such  an  ulcer  from
 getting well; and to  make  its apparance vary from
 that of an healthy ulcer.  These changes, when
 they occur, are generally to be considered as under
 the influence of the constitution.  There are three
 states  of constitution by  which the  appearance of
 ulcers is most commonly influenced.  The first is
 a generally disturbed state in which all the actions
 of the animal (Economy are  more rapid  than in 
96       OF ULCERS  IN PARTS WHOSE
 health, commonly  known by the  expression of the
 body being in an irritable state.

   The second is where  the actions  of the animal
 ceconomy are unusually languid which, to distinguish
 it from the former, is called an indolent state of the
 body.  The third is where the actions of the animal
 ceconomy are interfered  with by  some disease af-
 fecting the system : when either  of these states of
 the  general habit take place,  the ulcer acquires a
 correspondent disposition,  and is called,  irritable,
 indolent, or diseased.

   It would be natural to suppose these three  dis-
 positions so widely different from one another, that
 an ulcer attended with  irritability, one  attended
with  indolence, and one  attended by some  specific
 diseased action, must be very readily distinguished
 by their external appearance.   This, however, is
 by no means true ; for although in strongly marked
cases there is no  difficulty in judging  of the nature
of the ulcer from the state of the  granulations, this
mode of discriminating is not, in the greater number
of instances, at all to be relied on.

   The disposition of an  ulcer, like the  disposition
of a constitution, is only  to be exactly ascertained
by determining the actions  which arise from the 
ACTIONS ARE TOO VIOLENT          97
 different impressions made upon it.   From a  want
 of attention to this mode of considering the subject,
 ulcers have been commonly supposed to be of the
 same  kind,  where the  external appearances  were
 nearly  alike; which has  retarded the progress of
 our knowledge on the treatment of ulcers, by pre-
 venting a more judicious application of the medi-
 cines in use ; while, by employing them improperly,
 their character has been materially injured.

   In considering ulcers  in parts, whose actions are
 too  violent, attended  by irritablity,  it is proposed
 not  only to treat of those  which evidently are so in
 their appearance;  but to include  all ulcers, what-
 ever their appearance  may be, which locally or
 constitutionally partake so much of irritability, as to
 require sedative applications for their cure.  This
 will be found  to  comprehend a  much  greater
 number of ulcers  than could at first view be ima-
 gined.

  There are appearances which at once  show the
ulcer to be of an irritable kind, and these, when they
are  present,  render all further investigation  un-
necessary.  The following are  the principal marks
of irritability:

                       i 
98       OF ULCERS  IN  PARTS WHOSE
   The margin of the surrounding skin being jagged,
and terminating in an edge which is sharp and un-
dermined.   The bottom of the ulcer  made  up  of
concavities, of  different  sizes.   No  distinct ap-
pearance  of granulations, but  a whitish  spongy
substance, covered  with a thin, ichorous discharge.
Every thing that touches  the surface gives  pain,
and very commonly makes  it  bleed.

   In proportion to the degree of irritability or dis-
turbance, which has been produced in the action of
the parts, so is the discharge altered from common
pus to a serous fluid, and in some instances it is al-
most simple water, as in the following case.

   A gentleman, 60 years of age, of a very irritable
constitution, in March 1798 had a slight  kick upon
the inner ankle of the right leg, which at the time
was not  attended  to;  it did  not  heal, and  on the
fourth day from the accident  he became  generally
indisposed, which was considered to arise from the
disordered state of his stomach; he fainted away,
and upon recovering himself had all the symptoms of
a disturbed  state of the constitution, in common lan-
guage called fever : the sore upon the ankle inflam-
ed, Avas exceedingly painful,  the whole leg swelled,
and the scarf skin separated from the  cutis for  an
inch all round the ulcer, so that mortification was  to 
ACTIONS ARE TOO  VIOLENT.        99
be expected.  In this state I saw it on the seventh
day, and directed a poultice of bread and water; the
serous discharge was very great, the pain in the part
severe, and the constitutional indisposition unabat-
ed.   At  the  end of five  weeks, by the different
means used, which were  principally the bark, his
general health was in  some measure restored, but
the poultice had brought out pimples on the sur-
rounding  skin, and was therefore left off, and a sim-
ple white ointment applied; the  leg at this time
continued swelled, and pitted when pressed.

  The ulcer was about half an inch square, and, in-
stead of discharging common pus, it was a limpid
water, which in the course of 24 hours completely
wetted the compress and bandage ; this discharge of
water evidently diminished the  size of the leg, and
in 11 days it was reduced nearly to the natural size ;
after which  the ulcer began to heal, and in a fort-
night longer skinned over.

■  The ulcer, during the whole of this time, was in
an uncommonly irritable state,  could not bear the
slightest pressure, and was  attended with a great
deal of pain till the last fortnight before it skinned
over. 
100         OF ULCERS IN  PARTS  WHOSE
  A truly irritable ulcer is perhaps as distressing a
complaint as any in surgery, and too often as little
within the power of having its symptoms relieved;
the pain however, fortunately, in general, gradually
abates,  being too violent for the parts  or constitu-
tion long to bear.

  When in this state, the pain is not constant, but
eomes on in fits, usually in the evening or in the
night, and at thoae times is extremely violent, and
attended by spasmodic  contractions or convulsive
motions of the limb, which sometimes extend to dif-
ferent parts of the body.

  This symptom arises from the irritation being
communicated along the course of the nerves, pro-
ducing an  action in these  chords, attended with
violent contractions in the  muscles which they sup-
ply.

  To enter more fully into an explanation of this ac-
tion of the nervous  chords at present,  would break
in too much upon the general view of the different
symptoms met with in this species of ulcer now un-
der consideration ; it will therefore be  reserved for
another chapter. 
ACTIONS ARE TOO VIOLENT.        iOl
   When the marks  above mentioned are  not pre-
 sent, which very often happens, we are  frequently-
 led to a knowledge of the disposition of the  ulcer by
 the  previous  history of the case, and the effects of
 different medicines that have been used : but where
 there  is no s^ich history to be obtained, and the ap-
 pearance leaves us in doubt, it is prudent always at
 first to take up the treatment under the idea that the
 ulcer  is irritable ; as  it is an error, where  we are
 wrong, of the least consequence, and where right,
 we have a considerable advantage, in not only hav-
 ing gained the whole time of the experiment, but in
 having saved the patient from a great deal of unne-
 cessary pain.

   When an ulcer takes place immediately over the
 projecting part of the fibula, which  forms the outer
 ankle, it commonly puts on the appearance of an ir-
 ritable ulcer.  This seems to arise from  the nature
 of that part of the limb on which it is situated, inde-
 pendently of any constitutional or local  disposition
 for irritability.  It is probable that the periosteum,
 which at this part lies immediately  under the skin,
 becomes the seat of the ulcer, which renders it  very
 difficult to heal,  and gives it this particular appear-
ance.   I was led for  some years  to suspect, that, in
all such instances, the bone was injured, from  hav-
 ing found that to le the case in several very tedious
                        i  2 
102       OF ULCERS  IN PARTS WHOSE

ulcers  in this  part;  but have since seen many re-
cover, although very»slowly, without the bone being
exposed :  and therefore conclude, that the difficulty
attending the  cure, which is almost always found,
does not necessarily depend upon  the  state of the
bone.                                m

   This opinion is further strengthened by many ul-
cers situated upon the ligament of the patella, and on
the  periosteum of the anterior surface  of  the tibia
 putting on a similar appearance, and  being equally
tedious in the cure.

   The great  object to be kept in view, with regard
 to the management of ulcers,  is that of ascertaining
 with  accuracy their true nature.  Too much atten-
 tion cannot be paid to this investigation.   When it
 is completed, if the ulcer is ascertained to be of the
 irritable  species, little difficulty will remain.  All
 that is wanted will be to find out what particular se-
 dative application may be best si.ifed  to the case un-
 der our care, and the form in which it can be used to
 the greatest advantage.

    That  ulcers are rendered irritable, whenever  the
  actions of the constitution are increased beyond what
  is  necessary for health, cannot be better illustrated,
  than by  stating  what  has frequently  happened on 
          ACTfONS ARE TOO  VIOLENT.       103

board  the Fleet during the present war.  Ulcers
have become, in many ships, so general, that it ap-
peared to be an infectious disease spreading by con-
tagion ; the smallest scratch, even the orifice made
by  a clean lancet in bleeding,  degenerating into an
irritable  ulcer, and spreading to a considerable ex-
tent, not running along the skin, nor indeed so rea-
dily affecting the skin as the deeper seated parts, the
principal mischief being committed upon the cellular
membrane, muscles, tendons, and ligaments, the dis-
charge thin and ichorous, no appearance of granula-
tions, and when the tendons were exposed, nervous
twitchings taking place in the muscles.

   It would  st em difficult to account for so very sin-
gular a disease pervading a ship's company, at least
that the  constitutions  of the men should be so gene-
rally indisposed, that a breach of the integuments
immediately degenerated into  such an ulcer;  but it
appeared to Dr. Baird, the  Physician to the Baltic
Fleet, that in the ships, on board of which this took
place,  the  men  had been taken suddenly from  a
spare diet to a generous one;  and that the  mode of
treatment most effectual in his  practice was, redu-
cing their general strength by every means, as bleed-
ing, purging, and giving large  doses of the citric
acid, at the  same time giving  opium  liberally ;  but
where the strengthening plan was adopted, they not 
104      OF ULCERS IN PARTS  WilOal

unfrequently were obliged to have their limbs am-
putated.

  The only rational mode  in which this appears to
me to admit of explanation is, that the mens' bodies,
in a debilitated state, were too suddenly overloaded
by  supplies of  nourishment, which  excited  great
action in the heart and arteries, and hurried on the
circulation in these weakened parts, next the extremi-
ties ;  and when  an injury  had been  committed on
them, this violent action in the smaller vessels, instead
of restoring  what was  lost, produced ulceration.
This is exactly similar to the effects of warmth  to
a part which has been frostbitten:  in a part  so
weakened, the action is  too great, and mortification
ensues, but  snow, or very cold  water, would have
allowed the part to recover.  In the  one  case, the
violent action is constitutional,  in the other,  it is
local.   It is upon the same principle  that a fever,
when it attacks a person who has a common healthy
ulcer, shall  make it  worse, but if it is an indolent
one, shall effect  a cure.

  The variety which occurs among  constitutions
has been already noticed,  and  we find that  its
influence produces a similar variety in the disposi-
tions  of  ulcers.  It  will  therefore be   necessary
to have a number  of different medicines,  which
* 
ACTIONS ARE TOO VIOLENT.         105
  may  be used in different forms, and  of-different
  degrees of strength, so  as  to  adapt them to  the
  peculiarities of particular cases, even of the same
  species of ulcer.   It  is  this circumstance  which
  gives  the  surgeon, who has  the most  extensive
  knowledge  of the effects of different external  ap-
  plications, a material advantage; since having greater
  resources within himself, he will be able to vary his
  medicines,   and  will  ultimately  succeed, where
  another, whose  practice had been limited  to a few
  applications, would have failed of success.  The
 young surgeon  should therefore spare no pains in
  storing  his  mind  with  as  extensive  a stock as
 possible of this kind of knowledge.

   There is  a very curious fact respecting the treat-
 ment of ulcers, which makes this extensive experience
 of the  medicines which are applicable to them still
 more necessary : it is, that very few cases will con-
 tinue to heal, more  than for a certain time, under
 the same treatment; the effect which  any one  ap-
 plication  produced  at first being  lost by habit, so
 that it  becomes  necessary to change it  for some
 other.   This  change of treatment, after a certain
 continuance, is so necessary, that  even where the
transition is made from a medicine with considera-
 ble powers, to one, which, had it been originally ap-
plied, would have had  little or  no effect, will be 
 106       OF ULCERS IN PARTS  WHOSE

productive of an  evident advantage.   This, how-
ever, will be  of short continuance ; but if the change
is made to a medicine  of  equal, or nearly equal,
powers, the benefit will be more permanent.

   This fact corresponds  with what is stated to hap-
pen in the practice of medicine,  in many diseases
of the  system, both with respect to internal medi-
cines, and external circumstances.   A change of air
is often found to be necessary, not from a worse to a
better, but because  the  patient has continued too
long in the same air, so that it is simply a change
that is  wanted ; and benefit  would be derived from
it, even if it were made from a purer air to one  of
less salubrious qualities.
APPLICATIONS CONSIDERED WITH REFERENCE TO
            THIS SPJXIES OF ULCER.

  It will be proper to state the different applica-
tions suited to this species of ulcer; leaving it to the
judgment of the  practitioner to select such as  may
be adapted to the peculiarities of the cases which
are entrusted to his care.
1. In the form of vapour. 
ACTIONS ARE TOO  VIOLENT.       107
  Medicines in this form are more immediately ap-
plicable to irritable ulcers, than to any others, since
warmth very generally allays irritation, and soother
the sensations of the patient.

  The vapour of  common  water,  from its degree
of heat,  is very soothing to many  ulcers in an irri-
table state ;  it is, however,  very seldom used  by it-
self,  but  united with other  substances, which either
have, or  are supposed to have, some sedative quali-


  The vapour of  spirits mixed with that of water
adds to its powers of allaying irritation.

   Opium is used with advantage,  as a fomentation
in different forms : .such as the tincture of opium
sprinkled on flannels wrung out of hot water ; the
extract of opium dissolved in hot water; or a decoc-
tion of poppy-heads, heated, and applied by means
of flannels.

   Chamomile flowers infused  in hot water; the tops
•f wormwood boiled so as  to form a decoction ; and
the fresh or dried leaves  of hemlock boiled  into
strong decoctions ; are also used as fomentations.
The extract of hemlock, and extract of opium, dis- 
  108       OF  ULCERS  IN PARTS WHOSE

  solved in hot water, make a very useful liquor for
  fomenting, where there is much irritability.

    The great disadvantage attending the use of fo-
 mentations is, the short time they can be  conveni-
 ently applied at any one time ; but their beneficial
 effects in many instances remain for hours after they
 have been used.

   There are cases of irritable ulcers which are ren-
 dered more painful by the application of any thing
 warm.  In such ulcers there is generally  a disco-
 loration upon the limb,  of a mottled, purplish ap-
 pearance, for some way from the ulcer; the lower
 part of the  leg is also unusually cold.  When that
 is the case, fomentations ought  not to be used.   It
 will often be found, in those instances, that there is
 a tendency to mortification, the parts being extreme-
 ly weak, as well as irritable,  and scarcely  able  to
 support themselves in their present state, so that the
 action  excited by the warmth  hurries on the ulcera-
tion of the weakest parts, or produces mortification,
both of which processes are attended with pain.

  2. In a moist state.
e most simple application in this form is the corn-
poultice, which may be made with bread and 
ACTIONS ARE TOO VIOLENT.        109
water, with a little sweet oil, or hog's lard, or bread
and milk.  Water is often  preferred,  as the milk
very soon becomes offensive to the smell.   There
does, however, as far as the evidence of patients can
be relied on, appear to be some soothing property
in milk, since the parts are easier in many instances
tinder a poultice of that kind, than one made either
with water or decoction of poppies.  Linseed meal
has some advantages over bread in forming a poul-
tice ; it does not require oil, which is found often
to disagree with an ulcer, it has a degree of tenacity,
and can therefore be kept more immediately on the
part,  and it is more readily removed.  It is also
sooner made, all that is necessary being the pouring
boiling water on the  meal, after which the poultice
is immediately fit for application.   A mixture of
bread and linseed meal in different proportions,
makes a very good poultice, and is in many instan-
ces preferable  to the  linseed meal alone.

   The extract of lead dissolved in water has been
    i
much recommended  as  an application in form of
poultice ; and in many cases it answers' very well,
but in a great variety of instances it does not agree
with the parts ; and when long applied, it has been
known to bring on the lead cholic.   It should there-
fore be used with caution.  Lead applied to ulcers,
in patients whose constitutions are very irritable,
                         K 
110        OF ULCERS IN PARTS WHOSE
 very often disagrees, and not only irritates the sur-
 face to which it is applied,  but is  either absorbed
 or affects the extremities of the absorbents, so that
 they inflame,  and the glands through  which they
 pass become swelled: of this effect several instan-
 ces have come under my care, in which, upon leav-
 ing off the lead, the  syrmptoms have subsided.

   This is  the more  deserving  of attention,  as we
 are in general unwilling to attribute the unfavoura-
 ble changes any disease takes, to the mode of treat-
 ment, which, however, is not unfrequently the case.
 The following instance  is of this kind.

   A gentleman  about 60 years of age had  an acci-
 dent by which he broke his shin, to the hurt part he
 applied a solution of Goulard's  extract of lead; this
was on the 4th of October, 1798.  Impatient of con-
 finement, he increased  the strength of the solution,
 but the small slough  formed by the accident had not
 separated on the 8th of November; it  was not a
 quarter of an  inch  in diameter ;  the lymphatics of
 the leg and thigh, had become painful;  the leg and
foot were cold, and the glands between the thigh and
groin had swelled, and threatened suppuration. In
this state I saw him,  and attributed all these effects
to the solution of lead ;  it was immediately left off,
the glands in the  groin, and the small ulcer on the 
ACTIONS ARE  TOO  VIOLENT.
Ill
leg, were  bathed with equal proportions of decoc-
tion of poppies and chamomile flowers : in two days
the slough separated, and in four the glands subsid-
ed, and the ulcer healed under the use of powdered
rhubarb.   Spirituous applications had disagreed
with his skin upon former occasions, which led him to
use the solution of Goulard's  extract of lead ;  and
when  much diluted,  any hurt to which it had been
applied got well, but in this instance, it had been
made too strong, and had acted as a violent cause of
irritation.

   Decoction of poppy-heads makes a very useful
liquor for  a poultice ; this also disagrees in some
instances, but less frequendy with irritable ulcers,
than the preparations  of lead.

   Carrots  grated,  and beaten into a pulp form a
substance  which in  its  consistence  makes  a very
good poultice, and, from the properties of the car-
rot,  is well adapted  to  irritable ulcers; many of
them healing  more readily under its use than by
any other mode of treatment.   It is  curious to ob-
serve what slight circumstances make a material
difference in the effects of a medicine upon ah ulcer.
In a particular instance of an irritable ulcer, which
had been under the care of several different surge-
ons, and to  which a variety of applications had been 
112
OF ULCERS  IN PARTS WHOSE
 made, every thing that was tried disagreed with it,
 except  the carrot poultice ; even this, made in the
 manner above  mentioned, did not give it the least
 disposition to heal.  It was therefore proposed that
 the carrots should be  boiled and beaten into a pulp,
 before they were applied, the pain was immediately
 diminished,  and the ulcer healed by a continuance
 of that  application.

   As the greatest  objection to poultices, in most
 cases of this kind,  is  their weight, it becomes an
 object of attention, wherever it can  be done,  to let
 the limb rest upon the poultice, and not the  poul-
 tice  upon the limb ; when this cannot be managed,
 and the weight of its application gives pain and un-
 easiness, so as more than to counterbalance its be-
 neficial  effects, it will be better to change it for some
 lighter  application.

  Where poultices agree, it is a matter of  some
 consequence  to determine how long their use should
be continued.   This will depend principally on the
appearance of the granulations; if they are small,
and  the ulcer  is rapidly diminishing in size, no
change should be made till the cure is completed;
but if the granulations  are become large  and looser
in texture, it  appears proper to leave off the poultice,
even where the ulcer is evidently contracting. 
ACTIONS ARE TOO VIOLENT.
113
   It is proper to mention that many irritable ulcers
 will begin to  heal before they put on a healthy ap-
 pearance; and after they  have skinned  over  to  a
 considerable extent, the remaining ulcer shall still
 have a foul appearance ; while this is the case, the
 poultice should, I believe, always be continued.

   Where poultices cannot be used, in consequence
 of their weight being more than the parts can bear,
 one of the following solutions may be applied upon
 lint: extract of opium dissolved in water, decoction
 of poppies ; tincture of opium ; decoction of cicuta;
 aqua lythargyri acetati  composita; solution of ar-
 gentum nitratum, in a diluted state. The best mode
 of using these medicines would probably be keep-
 ing the parts constantly moist, by renewing the ap-
 plication  as  often  as  it became dry ; but  as this
 would be attended with a great deal  of trouble, it
 cannot  be pursued as a general practice ;   and  a
pledget of white  ointment  over the  dressing pre-
vents the lint from drying and sticking to the  sur-
face of the ulcer.

   3. In a dry form.

   For ulcers of this species there are few medicines
in form of powder that are sufficiently mild in their
properties to admit of being employed.
                       k 2 
114       ,OF ULCERS IN PARTS WHOSE

  The carbon has been lately introduced into prac-
tice, and  by  some  practitioners  highly  extolled.
From what experience I have had of it, it appears
to be an useful medicine, in many cases of irritable
ulcers ; having found it to agree where other more
common applications have failed.   It has this dis-
advantage, that  its colour prevents the surface of
the ulcer from being distinctly seen at each dress-
ing ; and  any attempt to  wipe it clean gives  pain,
and irritates the granulations.

  The extract of opium, in the form of powder,
mixed with  the carbon,  in equal proportions, or
with any  other powder, as the linseed flour,  is an
useful apphcation.   It is a circumstance deserving
of observation, that in some cases  the opium is ab-
sorbed in sufficient quantity  to affect the system,
and produce sleepiness.  When this happens,  it is
difficult to determine whether the benefit arises from
the immediate action produced on the ulcer, or the
effect the  opium has upon the system.

  Opium, externally applied, sometimes gives pain,
and when that happens, it generally aggravates the
other symptoms.

  The extract of opium in some cases appears to act
.is a poison, producing the most violent effects of in- 
          ACTIONS ARE  TOO VIOLENT.       115

flammation, which terminate in mortification ;  these
however, are rarely met with ; the possibility of such
an effect taking place becomes a strong reason against
the  application of opium  in so concentrated a form,
where there is a  great degree of irritability  in the
parts.

  The following observations made by Mr. Adair,
while surgeon to  Chelsea Hospital, on the use of
opium to ulcers,  has been communicated to me by
Dr. Heberden, who found them among his father's
papers, to whom they must have been given by Mr.
Adair ; they confirm in  the  strongest manner the
above-mentioned circumstances in favour of the lo-
cal  use of that medicine.

  " In Chelsea Hospital there are  many old ulcers
of the legs, which frequentiy, in a short space of time,
increase in size, and become very painful, and trou-
blesome to manage.

  " In April and May, 1780, several of these ulcers,
which had increased in size, and become very pain-
ful, were dressed with lint,  dipped  in a  solution of
opium in water (in the proportion of an ounce  of the
extractum thebacium, to  a pint of water) at the same
time, some ulcers in  the same state, were dressed
with a poultice of bread,  into which  half an ounce of 
116       OF ULCERS  IN PARTS WHOSE
the above solution was put:  in all these cases, im-
mediate ease and sound sleep, were procured; (al-
though  to most of these  patients opium had been
previously given by the mouth, and had not procur-
ed them sleep ;) and they remained drowsy through
the day:  on continuing  these applications  a few
days,  repeating them night and morning, some pa-
tients  complained of pain in the head, with dimness
of sight; others of sickness, diarrhoea and pain in the
bowels ; in all their  sleep was disturbed ; and the
discharge  from all their ulcers was much lessened.
Those patients, who were treated with the solution
in the poultice, neither felt these complaints so early,
nor so violently, as those who were dressed with lint
dipped in the  solution.   In all these patients,  on
leaving off the use of  the solution, their complaints
disappeared, and the discharge from their ulcers re-
turned as  before.

  " On  December 23d, 1780, two patients were af-
fected with  the same painful kind  of ulcers, and
were  dressed with lint,  dipped  in a solution  of
opium in water, much weaker than the former  (a
dram  of extractum thebacium to a pint of water.)
On the 25th, the first patient was attacked withpain
in his bowels,  and a slight  purging.   26th. His
complaints were increased, and he complained also
of pain in his head, and giddiness; the solution was 
          ACTIONS  ARE  TOO VIOLENT.       117

left off this day, and his complaints went away gra-
dually.   The second patient did not make any com-
plaints, before the 26th, when his bowels were unea-
sy, and he was affected with giddiness, and dimness
of sight: the  solution was now applied only once a
day.  29th.  His symptoms having  increased, the
solution was left off entirely, and his complaints left
him :  in  both these cases ease was procured on the
application of the solution, as in the others;  in both,
the discharge  from  the ulcers was diminished, and
increased again on leaving it off."

  4. In an unctuous form.

  This form of application is not well adapted to the
generality of irritable ulcers, for the following rea-
sons.   The oil or lard, which makes a part of the
preparation, is generally  rendered more or less ran-
cid, as has been already  noticed, by the process of
forming the ointment, which is commonly by means
of heat.   It also happens, that the skin of persons
whose habits are irritable, and who are therefore
most liable to ulcers of an irritable nature, frequent-
ly will not bear the application of common ointment.
Under such circumstances very few unctuous dress-
ings can  be used. 
118
OF ULCERS  IN  PARTS  WHOSE
   In some cases of irritable ulcers, cream, where it
can be procured, is often a very soothing application ;
the  cases in  which it answers best are  where the
parts cannot bear warmth,  the pain being increased
by it;  there is a  coldness  in the cream, which in
such instances considerably mitigates the painful
sensations.

   As a substitute for cream the following ointment
is used  with advantage:  hog's lard purified by fre-
quendy washing it in spring water, and then made
into an ointment, with a small portion of white wax
and  rose water.

   The  unguentum cerussse acetatse agrees  in some
particular cases, but in many others it appears to do
harm j the same caution is therefore necessary here
as when the solutions of lead are employed.

   These are the only ointments in general use that
can be recommended in ulcers which  belong to this
class.

   5. Bandages.

   In this  species  of ulcer benefit will rarely be
derived from  compression.   The surface  of the
ulcer is,  in general, unable  to  bear  any  pressure 
ACTIONS ARE TOO VIOLENT.
119
without being rendered more painful, and whatever
gives pain proves in these cases injurious.  The
bandage employed should only be sufficiently tight
to retain the dressings in their place ; nor should it
even be more so, upon the  other parts of the leg.

   It does happen-that  a tight bandage will bring
on spasms which extend all the way up to the body,
and when the compression is removed, they go off.

   In  other cases where there is a less degree of
irritability,  and that arising from weakness,  com-
pression within certain limits may be used with the
greatest benefit.
  In this species of ulcer it is very difficult to give
any particular directions respecting those medicines
that are to be tried in preference to others.

  Poultices are the safest to begin with, and when
it shall be thought  right to change  the application,
the surgeon will have  acquired a degree of know-
ledge of the disposition of the ulcer, and the pecu-
liarities of the constitution, which will guide him
in his future choice. 
120         OF ULCERS  IN PARTS, &C.

   If the degree of irritability be very great, he will
adopt  those  medicines  which  are the mildest  in
their nature, softest in their form, and can be used
with the least  pressure  arising from their weight.
Among these  cream, or the ointment substituted
for it, are probably the best applications.

   If the irritability  is not great, but the parts little
disposed to heal, the weak  solution of the argentum
nitratum is one of the best medicines. 
CHAPTER VI.
EXPERIMENTS AND OBSERVATIONS ON  THE  IRRI-
  TABILITY OF NERVES, BY WHICH THE SPASMODIC
  AFFECTIONS ATTENDANT UPON IRRITABLE UL-
  CERS ARE ACCOUNTED FOR.


X  he  nerves have  been hitherto considered  as
chords that  have no powers  of contraction within
themselves, but only serving as a medium, by means
of which the influence of the brain may be commu-
nicated to the muscles, and the impressions  made
upon different parts of the body conveyed to  the
brain.*

  The difficulties which attend every attempt  to in*
vestigate the real state of the nerves  in the living
body, and the impossibility of acquiring any  infor-

  * These observations on the irritability of nerves were laid
 before the Royal Society in November, 1800, and have a place
 in the Philosophical Transactions.
                        L 
122
UN THE IRRITABILITY.
 mation upon this subject after death, may be urged
 in excuse for this opinion having been so universally
 received, since it will be found, from the following
 experiments and observations, to be void of found-
 dation.

   The only means by which any knowledge respect-
 ing the irritability of nerves can be procured, must
 be from the operations  in  surgery performed upon
 nerves, either in a healthy state, or under the influ-
 ence of disease ; or  from  experiments made upon
 animal bodies before they are wholly deprived of life,
 and instituted for that pa rticular purpose.

   My attention was directed to this subject by the
 following case, which explains many circumstances
 respecting the actions of the nerves when under the
 influence of disease, and  gave rise to  the experi-
 ments and observations  contained in this chapter.

  A person thirty-six years of age, naturally eager
 and anxious in his  disposition, whose stomach was
 peculiarly irritable and irregular in its action, in the
 winter of the  year  1796, while riding in the coun-
try, was thrown from his seat by a sudden  motion
of the horse ; and in endeavouring to save himself,
fell with his whole weight upon the  end of his
thumb, against the pommel of the saddle. 
           OF  THE NERVOUS  CHORDS.        123

  The  part swelled, and  became  very painful.
A few days after, he hurt it again, which prevented
the swelling from subsiding, and it remained uneasy
and enlarged for three or four months.   It after-
wards got well, but the motions of the thumb were
not always under the command of the will; so that
he was sensible, in the years 1797 and 1798, while
writing, of finding a difficulty  in forming particular
letters.

  On the evening of the 16th of October, 1799,
which was cold and damp, he was  travelling in a
post-chaise with two  other persons, and let down
the window, to speak to the driver.  A  cold wind
blew directly into the carriage, and he endeavoured
to pull up the  window; but,  not seeing  the glass
rise, he looked down, and his  hand, instead of pull-
ing up the window,  was lying upon his knee.   The
thumb was bent in towards the palm of  the hand ;
a spasm came upon the muscles of the arm, making
them bend the elbow ; and immediately he became in-
sensible : in a quarter of an hour he perfectly recover-
ed himself. Some hours  after, upon his bending his
thumb, to shew  what had happened to  him in the
carriage, there was a  return of the same  attack,
which also rendered  him insensible  for  a  few
minutes. 
124
ON THE IRRITABILITY
   From this time, he had no return of these attacks
 for nine weeks ; at the end of which period, on the
 18th of December, 1799, he  was waving his hand
 over his head, with a degree of eagerness, as a sign
 for some people to make haste and follow him ;. this
 exertion made the thumb contract towards the palm
 of the hand, and he fell upon the ground in a state
 of insensibility.  This attack went off as the others
 had done ; he had  another in the evening;  and, in
 the course of the next day, two more, equally violent.
 As the motion of the thumb was the first symptom
 in all these attacks, the assistants were led to contrive
 a glove, the front of which was strong  enough to
 resist the motion of the thumb, and to  keep it in its
 place ; while this was kept on, the attacks were less
 frequent.  A  ligature  was then applied round the
 fore-arm;  when the thumb was beginning to be
 agitated, this was tightened, and  the spasms  were
 found to be arrested at the ligature, and of course
 deprived of their violence.

   From this time, a tourniquet was kept constandy
 upon the fore-arm; and  a  person was  always in
readiness to tighten it, the moment the  spasm  was
expected, which was always preceded by a general
 feel  of uneasiness all  over  the body: as  soon as
the spasm went off,  which it did instantaneously,
the tourniquet  was loosened.   The spasms  in  the 
OF THE NERVOUS CHORDS.
125
 thumb  and fore-arm returned frequently, and at
 irregular  intervals,  generally every three hours,
 sometimes oftener, and once did not come on for
 thirty-six hours.

   On the third or fourth day, electricity was tried,
 with a view to relieve them ; sparks drawn from the
 thumb, produced tremors  in the  muscles, which
 were  confined  to the  thumb.  An  electric shock
 through the ball of  the thumb, brought on a very
 severe spasm in  the arm ;  but neither sparks, nor
 a shock through the other thumb, produced any sen-
 sible effect.

   On the 29th of December, I first saw the patient;
 and, after watching the symptoms for three days,
 made the following ovservations upon  the com-
 plaint.

   That the  beginning of the attack was some in-
 voluntary motion of the thumb and fore-finger; and
 therefore, the disease appeared to be  in the branch
 of the nerve which supplies these two parts, called
 by Winslow, the median nerve.

  That the progress of the spasms was in the direct
 course of the trunks of the median nerve,  up to the
head.
                     i. 2 
126         ON THE IRRITABILITY.
  That compressing the parts in the course of that
nerve,  when it was  done before the spasms had
reached them, always arrested their progress ; but,
when once the muscles had become convulsed,  or
agitated, the same compression had no effect in stop-
ping the progress of the spasms.

  The mode in which the spasms were propagated
along the course of the nerves,  was as follows.

  Five or six tremors took place  in the flexors of
the thumb and fore-finger; then similar convulsive
motions affected the  muscles of the fore-arm ; soon
after, the muscles of the  arm were thrown into the
same kind of action  ; afterwards the pectoral mus-
cle, and scaleni of the neck: the muscles of the lower
jaw were probably in the same  state, although their
action was not within the notice of the by-standers.
The head was pulled forcibly to that side, in quick
successive motions, and in a  second  or two, the
•whole ceased; the parts became tranquil, the insensi-
bility went off, and  the patient recovered himself:
there  was, however, a general feel of langour and
distress over the whole body, before the recovery.

   From these observations, the disease appeared to   <
be  decidedly in  the inferior branches of the median
nerve  ; and the irritation  was conveyed  along  its 
          OF THE NERVOUS  CHORDS.         127

course, from its terminations in the thumb and fore-
finger, to the origin in the brain.

   It was proposed to divide the nerve, as it passes
from under the annular ligament of the wrist towards
the  thumb, to cut off  the communication between
the diseased  extremities and the trunk of the nerve,
and so put a stop to the  progress of the  irritation
which constituted the diease.

   That such an operation might be attended with
success, was not only rendered probable from reason-
 ing, but the performing it was fully justified by the
 success which had been experienced from a similar
operation, in some cases of the tic douloureux ;
a disease, in many respects, of the same nature with
the present.

   All these circumstances were  explained to the
patient, who from a  desire of obtaining relief, con-
sented to have the nerve divided.   This was done
on the first of January, 1800, in the following man-
ner :  the nerve, as it passes from under the annular
ligament, towards the thumb and fore-finger,  was
laid bare, for above  an inch in length :  it was then
detached from  its lateral connections, and, in  this
exposed state, a probe-pointed bistoury was passed
behind it,  and the nerve was raised upon the edgfc 
 128          ON THE IRRITABILITY
 of the instrument, so as to be distinctly seen by the
 different medical gentlemen present, before it was
 cut  through.  As soon as it was divided,  the two
 cut ends retracted from one another, to a considera-
 ble distance.  This retraction was very unexpected,
 as the nerve was disengaged from the cellular mem-
 brane, and no other  part had been divided, whose
 action could make the  portions  of the nerve re-
 cede.

   That nerves, when divided,  do  retract, is well
 known in  the practice of surgery;  but this effect
 has been usually attributed to the contraction of the
 neighbouring parts, as the  cellular  membrane and
 blood-vessels, with which the nerves are connected.
 As none of these causes could produce the effect in
 the present instance,  it was natural to suppose, that
 an independent action existed in  the  nerve itself,
 which had  been so much increased by the influence
 of disease, as to become unusually great; and there-
 fore, the retraction was more distinctly seen than in
 a healthy state of the  body.

   The moment the nerve was divided,  there was a
spasm  over the whole body,  and a  momentary in-
sensibility.    The blood-vessels  divided in the ope-
ration were not secured by ligature, but allowed  to
stop of themselves, to give the wound every chance 
OF  THE NERVOUS  CHORDS.        129
of healing by the first intention.  The edges of the
skin were carefully brought  together, and  kept in
in that state by compress and bandage, to promote
as much as possible the union.

  For eight hours  after the  operation,  the  parts
were perfecdy quiet,  and there was no spasm.  The
wound then began to feel hot, as if a red hot coal
had been applied to  it.  To relieve this sensation,
the outer bandage was loosened, and immediately
there were twitches in the nerve, which soon went
off.  The patient felt himself generally unwell, ex-
tremely nervous, and irritable.

  Ffteen hours after the operation, he had a violent
spasm, which went along the arm to the head, but
did not affect the brain.   In an hour there was a
second  attack, at which I was present;  the  pulse
was 105 in a minute, the tongue white, a great deal
of general irritation,  nervous twitches all over the
body, but in the greatest degree in the arm  and leg
of that side.  The stiff-fronted glove was now put
on, to confine the thumb.

  Twenty-four hours, or one day, after the opera-
tion, the first dressings were removed : the thumb
was much swelled, and no union whatever had taken 
 130         ON THE IRRITABILITY.

 place ;  the spasms returned  every five hours,  but
 were less violent.

   The second  day,  there was no abatement of the
 symptoms, but the spasms did not affect the brain ;
 they were  not now stopt by the pressure of the
 tourniquet, as they had been  before the operation.

   The third day, there were intervals of ten hours
 between the  spasms ;  and, in the  night, they did
 not extend beyond the elbow.

   The  fifth  day, suppuration took place in the
 wound; the swelling in the hand was much abated j
 and the patient was able to dress and shave without
 spasm,  having only twitches in the fingers, and tre-
 mors in the fore-arm.

   The  sixth day,  there was  a burning pain in the
 hand, and a numbed heavy feel in the thumb  and
 fore-finger, similar to  what the patient recollected
 to  have felt  four  years  before, when  he hurt his
 thumb.

  The seventh day, the  patient  awoke with great
pam in  the hand, succeeded  by a violent spasm,
which passed  up to the head, although the tourni- 
OF THE NERVOUS  CHORDS.        131
 quet had been previously tightened : after this, he
 had no spasm for sixteen hours.

   The eighth day, the hand was less swoln and less
 painful; and  he  had only two  spasms in twenty-
 four hours.

   The ninth day, the swelling had subsided, and the
 twitches ceased;  in thirty hours, there was only one
 slight spasm, which did not go beyond the wrist.

   The sixteenth  day, the wound was entirely heal- '
 ed; and, as  there had been no return of spasms, the
 patient was  considered as well.

 '  On the twenty-fourth day, which was a fortnight
 after the spasms had ceased, at  nine o'clock in the
 morning, he was awakened by a violent spasm,
 which passed directly up to the head, and affected
the brain, producing insensibility ;  this was the on-
ly  time the brain had been affected since the opera-
tion.

   Two  days previous to this attack, he had a vio-
lent diarrhoea ;  and, on the preceding day,  had un-
 dergone unusual fatigue. 
132
ON THE IRRITABILITY
   The tourniquet which had been laid aside, was
now applied;  and,  for  the  greater security, two
were placed on the fore-arm, and one upon the arm
itself.  At  six in the evening, there was another
spasm, attended by insensibility, although the tour-
niquets had been tightened.  The hand was found
swoln, as well as the wrist, and the cicatrix formed
a hard welt, tender to the touch.  This hard state
of the cicatrix, in which the end of the divided nerve
was included, appeared to be  a probable cause of the
return of the spasmodic attacks.

   The twenty-fifth  day,  the pulse  was 100 in a
minute;  and, every two hours,  there were slight
spasms.

   The twenty-sixth  day, there were eleven spasms
at irregular intervals, in twenty-four hours, eight of
which, went up as high as the head.  As the spasms
were not stopped by the tourniquet, as before, it
was proposed to make the pressure direcdy upon
the nerve :  this was  done by  placing pieces of cork
in the course of the nerve, and confining them there
by  the band of the  tourniquet, so that, when the
screw was tightened, the cork was pressed down on
the nerve.   This pressure gave great pain, and, in-
stead of arresting the progress of the spasms, seem- 
OF THE NERVOUS CHORDS.         133
 ed rather to increase their violence ; it  was there-
 fore left off.

   The twenty-seventh day, the pulse was only be-
 tween 80 and 90  in a minute ; there  were seven
 spasms, all of which were arrested by the first or se-
 cond tourniquet.

   The spasms went on with very little variation, till
 the 39th day at six  o'clock  in the morning, when he
 was seized in his sleep with a violent spasm,  attend-
 ed with insensibility, and convulsions over the whole
 bodyr: these lasted for twenty minutes.   After his
 recovery, the hand  was found much swoln, and the
 welt formed  by  the  cicatrix was painful.  In the
 course of the forenoon he was well enough to bear
 going out in the carriage ; the fresh air always prov-
 ing very grateful to him.

   From this  time, the swelling of the hand and the
hardness of the welt diminished ; and the spasms
were less violent, and seldomer.   On the 45th day,
there was only one slight spasm in twenty-six hours.
In this state he went into the  country ; and, for the
first fortnight, the  spasms  diminished,  but after-
wards became more violent.
M 
134        ON THE IRRITABILITY
   The return of the spasms, after the wound had
been healed, made it evident, that the operation of
dividing the nerve had not  answered the purpose
which was expected from it.  The failure probably
arose from the wound not healing by the first inten-
tion : the consequent inflammation rendered the cut
end of the nerve uncommonly irritable ; and, in this
state, the confinement in the hard thickened cicatrix
rendered it liable to be stretched  by every motion of
the  thumb, so as to bring on spasmodic contrac-
tions.

   From this time, the patient was not under my di-
rection ; but I understood, that  he tried the effect
of large doses of opium, which did not afford relief.
He  was then induced to employ electricity,  which
was also unsuccessful; and he died in a fit,  which
at the time was  believed to be apoplexy, about five
months after the  operation  had  been performed;
but, as the body was not examined, the nature of the
fit could not be ascertained.

   In this case, some of the branches of the median
nerve had acquired, from disease,  an unnatural pow-
er of contraction, which was made evident by the
operation; and there is every reason to believe, that
the  spasmodic attacks which took place were in
reality convulsive motions in the nerves themselves, 
          OF THE NERVOUS  CHORDS.         135
which excited corresponding contractions in those
muscles that were under their influence.

  This case  naturally occupied my mind; and  I
could not avoid dwelling upon many of the extraor-
dinary symptoms which  made a part of it; but no-
thing so impressed itself upon me, as the retraction
that took  place in the cut ends of the nerve, at the
time of the opera ion.

  The first idea which suggested itself was, to en-
deavour to ascertain  whether this retraction arose
from  an increase of a natural action in the nerve, or
from  one newly acquired, produced by disease.

  With a view to ascertain this point,  different ex-
periments were instituted.  The object of these was,
to determine whether a  similar contraction took
place in nerves, when divided in a healthy state of
the  body; the extent of such contraction, if any oc-
curred ; and the circumstances by which  it may be
influenced.

  For the first of these purposes, the following ex-
periments were made.

  Exper. 1.   The cutaneus internus nerve of the
fore-leg of a young rabbit was laid bare, where it 
 136         ON THE  IRRITABILITY

 passes down before the biceps flexor cubiti muscle:
 the nerve was disengaged from its lateral attach-
 ments ; and, while the  limb was in a moderately
 extended state, a probe-pointed bistoury was passed
 behind it, by which means it was divided transverse-
 ly.   The two ends immediately receded  from each
 other: the upper portion appeared to retract  more
 than  the other, and the end lay close to the muscle,
 in a straight line, while the end of the lower portion
 was a litde bent to one side.  The space between
 tijem, when measured by a pair of compasses, was
 found to be f of an inch.

  The branch of the musculo-cutaneus nerve, which
 lies near to the cutaneus internus, was divided  in the
 same manner; and the retraction of the cut ends
 was found to have been to the same extent.

  In  this experiment the  limb was extended, al-
 though by  no means to its  utmost limits  ; it there-
 fore became a question, whether the same degree of
 retraction would  take place in the  bent state of the
 limb.

  To determine this point, the experiment was re-
 peated, after an interval of four days, upon the other
fore-leg of the same rabbit, with the limb in the bent 
           OF  THE  NERVOUS CHORDS.          137

 state:  the retraction, however, was found to  have
 been exactly to the extent of f- of an inch.
    From  this  experiment, made  under these dif-
 ferent  circumstances, a retraction of the cut ends of
 a divided nerve was ascertained to take place, which
 led to  the further prosecution of the inquiry.

    For this purpose, the phrenic nerve  in the horse
 was selected,  as  being more favourable, in manv
 respects, than most others in the body, both from
 its  superficial  situation in the  chest, and its great
 extent  without giving off any branches.

   In making  experiments of this  nature, it is an
 advantage that the animal should be of a large size ;
 and the mode in which horses are killed in London
 affords an opportunity of  experiments being made
 on  that animal,  without  giving  the operator  the
 painful sensations of having made any addition to
 its  sufferings.

   As horses are killed at stated times only,  and
 these occur in a part of the day which is necessarily
 occupied by my professional engagements, the  fol-
lowing  experiments  were  made by  Mr. Clift,  the
Conservator  of the  Hunterian  Museum, whose
accuracy may be relied upon, as  well as his abilities
in  conducting them, having been early  initiated,
and long experienced, in inquiries of this nature.
                  M 2 
138
ON THE IRRITABILITY
  Exper. 2.  Immediately upon a horse  having
been knocked down, the thorax was  laid open, and
the phrenic nerve of the right  side, passing round
the pericardium, was exposed. It was nearly of the
size of a crow-quill, and  slightly  connected  with
the pericardium.  In this state, the point of one
blade of a  pair of scissars was  passed under the
nerve; and, by closing them, the nerve was trans-
versely divided, without the smallest disturbance to
its lateral connections.   The two cut ends immedi-
ately retracted from  each other, leaving the space
of one  inch between their extremities.

  This experiment  was repeated upon a  second
horse; and  the retraction  of the cut  ends of the
nerve was found to be exactly one inch.

  It was repeated upon  a third horse;  and the
retraction was  found to be nearly two inches.  In
measuring  the  space between the two  ends of the
nerve,  the compasses accidentally touched the lower
portion, and the diaphragm was immediately thrown
into action.

  The result of this experiment  not only confirmed
the former, which had been made upon the rabbit,
but it proved, in the  most satisfactory manner, that
any action the  nerves  are capable  of exciting  is 
OF THE NERVOUS CHORDS.          139
nearly as strong after apparent death has taken place,
from a violence committed upon the brain, as while
the animal is in perfect health.

   Monsieur Portal, in a paper on  a new mode of
performing the operation of amputation,  published
in the Memoires of the  Academy of Sciences for
the year 1773,  mentions an experiment made on the
sciatic nerve of a dog, in proof of nerves not having
a power  of retraction, at least none deserving of
notice.*

   This experiment was repeated by Mr. Clift, on
the  sciatic  nerve  of  a  rabbit.  Immediately  on
dividing  the nerve, the cut ends  receded  from one
another: but, that the result might be exactly ascer-
tained, the rabbit was killed half an hour  after  the
experiment was made ; the parts were carefully dis-
sected, and the  space between the two  cut ends
measured ; which was exactly -^ of  an inch.

   To  ascertain whether  this  retraction   was  the
consequence of a change taking place in  the nerve
itself, or arose from any other cause, the  following
experiment was  made.

   * Memoire sur une  nouvelle  Methode  de pratiquer 1'
Amputation  des Extremites, par M. Portal.
         Histoire de 1' Academie des Sciences, 1773. p. 542. 
140
ON THE IRRITABILITY
   Exper. 3.   As  soon  as  a horse was knocked
down, the chest was laid open, and the phrenic nerve
of the right  side  was exposed : twelve inches in
length were  immediately measured by  a pair of
compasses ; and  the  limits of  this portion  were
marked by a  small pin, passed transversely through
the substance of the  nerve.  The part  included
between the two pins  was then separated from the
rest of the nerve, in  the following manner.   The
person who was to divide the nerve had a pair of
scissars in each hand ; and  having passed the point
of one of the  blades under the nerve, above  the  up-
per pin, and having done the same with the blade
of the other  pair of scissars, below the lower pin,
the two pair of scissars were shut at  the  same
moment,  and the  nerve  at  these  two  parts  cut
through.

   This portion was again measured,  and, instead
of being twelve inches, was now  only eleven and j;
so that the irritation produced by dividing  it  had
made it contract £  of an inch.

  This experiment was repeated upon several hor-
ses ; and  in  all these  repetitions  there was a con-
traction produced :  this varied in the different ex-
periments, and in  some  of them was only | ths of
an inch.  When the nerve was divided very early 
OF THE NERVOUS  CHORDS.
after the animal had been knocked down, it was the
greatest; and,  in proportion to the delay that took
place, so was the  diminution in the degree of the
contraction.

  In  these experiments, the nerve, as well  as the
surrounding parts, was disturbed as little  as possi-
ble, that the results might be the more readily and
more accurately ascertained :  this, however, makes
them liable to  an objection, which is, that the con-
traction might be produced by the cellular mem-
brane surrounding the  nerve ; an objection which
certainly can have little weight in the peculiar  situa-
tion of the phrenic nerve, as it lies between the pleura
and pericardium,  where the cellular membrane can
have little influence over it, while the pericardium
is left entire.

  As, however, the opinion of the cellular  mem-
brane being the agent, by which the retraction of di-
vided nerves is produced,  has been very  generally
received, it was highly proper to attend  to that cir-
cumstance,  and have the experiment made in such
a way  as  to prevent  any other surrounding part
from acting  upon the nerve;  with this view, the
following experiment was made.
  Exper. 4.  The pleura was removed from twelve 
142         ON THE  IRRITABILITY
 inches of the phrenic nerve of a horse ;  and after-
 wards the attachments between the nerve and peri-
 cardium were completely divided : under these cir-
 cumstances, this portion of nerve was separated, as
 in the last experiment.   This  portion  was again
 measured, three hours after, in its detached state,
 and it was found to have lost f of an inch in length.
 The  horse was  twenty years  old,  and was killed
 on account of its age, which rendered it by no means
 a favourable subject for such an experiment.

   With  a view to determine whether the power of
 contraction in  a nerve continued  for any length of
 time after apparent death had taken place, and also
 to ascertain what proportion of elasticity a nerve
 possesses (for every part of an animal'body that is
 not rigid appears to be endowed with it in a greater
 or less degree)  the following experiment was made.

   Exper. 5. Eighteen inches in length of the phre-
 nic nerve were  measured, and separated by means
 of scissars : the contraction produced was only | of
 an inch ;  the experiment being made nearly an hour
 after the  horse  was  knocked down.  Upon being
 stretched with  force,  it elongated  to 18| inches;
and, on being left to itself, retracted to 17}.  It was
kept till next day, and again measured, when it was 
OF THE NERVOUS CHORDS.        143
only 17|:  upon  being  stretched,  it was elongated
to 18£; but,  immediately on being left to itself,  it
retracted to 18 inches.

   This experiment  was  repeated  upon another
horse ; and the result was similar, both with respect
to contraction which took place after the nerve had
been removed from the  body,  and  the  elongation
which depended  upon elasticity.

   To ascertain if there was any difference in the ap-
pearance of a nerve  when contracted, from one in
a  relaxed  state,  the  following  comparison  was
made.

   Exper.  6.  A  portion of the phrenic nerve, about
eight inches  long, was removed immediately after
the horse had been knocked down.   This was al-
lowed to contract; and after it had remained quiet
for twenty-four  hours, its external  surface was ex-
posed by dissection, so that the  appearance of  its
fibres could be distinctly  seen.  A portion of the
same length  was removed from another horse who
died a natural death, and these were compared to-
gether.

   The difference  in the appearance  of these two
portions was very great: in the  contracted nerve, 
  144          ON  THE IRRITABILITY

 the fibres were all serpentine ; in the other they were
 straight.

    The serpentine transverse lines described by Mon-
 ro appear to be an effect of this contraction of the
 nerve ; as they disappear when the nerve is relaxed
 or elongated.*  These serpentine lines in the phrenic
 nerve, in a man  who died of  a locked jaw, when
 examined twenty-four hours after death, were much
 more distinct and regular than  in the  phrenic nerve
 of a man who died of a mortification of his arm.

   These experiments, upon so large an  animal as
 the horse,  made by a person well qualified for the
 purpose, and repeated sufficiently often to preclude
 any material fallacy, admit of the following conclu-
 sions being drawn from them.

   * " When the nerve is fully relaxed, these serpentine trans-
 verse lines are best  seen;  when the nerve  is moderately
 stretched, they are much less evident j when the nerve is great-
 ly stretched, beyond what it ever is in a living sound animal,
 it appears uniform in its colour and consistence.  Hence these
 lines, are in the first place, to be considered as folds or joints
 in the nerve, and may be compared to the lines in the palm of
the hand, serving to accommodate the nerve to the different
states  of flexion and extension."  (In  a note)  « By soaking
in water, this appearance is lost."
                    Monro on the Nervous System, p. 39. 
OF THE NERVOUS CHORDS.         145
  1. That the nerves of an animal in health are ca-
pable of retracting themselves when divided;  and
that this effect is entirely independent  of the parts
by which they are surrounded.

  2. That this  contraction takes place in  the ner-
vous fibres  themselves;  and  is independent of the
brain, from which they originate, and  of the mus-
cles and other parts, in which  they terminate.

   3. That the contracted nerve exhibits to the eye
an  appearance of contraction  in its fibres, not to be
seen when it is in a relaxed state.

  As the nerves are so readily influenced by elec-
tricity, in exciting the muscles to  action, it natu-
rally suggested  itself, that  some further  informa-
tion might be obtained in the  present investigation,
by means of experiments made upon the nerves by
the electric fluid.  With this view, the following
experiments were institurted ;  and Mr. Carpue very
obligingly  assisted Mr. Clift in making them, and
carried one of Mr. Cuthbertson's  large plate-glass
electrical machines to the slaughter-house for  that
purpose.

   Exper. 7. A portion of the phrenic nerve, twelve
inches long, was exposed and divided at both ends,
                        N 
146          ON THE IRRITABILITY
 as in the former experiments.   When  it had con-
 tracted to 11|, a strong electric  shock was passed
 along its substance, from one end to the other;  but,
 when measured again,  the length was  exactly the
 same.  The portion  of nerve was  then dissected
 out, and laid upon a piece of glass ;  in its detached
 state, it measured llf.   Several  strong electric
 shocks were passed through  it, in the direction of
 its fibres ; but they did not produce the smallest ef-
 fect upon it.

  This  experiment  was repeated  upon  another
 horse, and the result was the same.

  Exper. 8. Half an hour after a horse had been
 knocked  down, 24 inches in length of  the nerve
 called par vagum were  laid bare, and a portion of
 it detached  from its lateral connections, so that a
piece of glass, 12 inches  long, was admitted under
it, without  dividing the nerve from the trunk; in
this state, electric sparks were drawn from it, and
several  strong electric shocks  passed through it;
but there was not the smallest change to be per-
ceived, either in its length or appearance.

  From these experiments it appeared, that when
the nerve had contracted itself, in consequence of 
OF THE NERVOUS CHORDS.        147
being divided, no increase of that contraction was
produced by the electric fluid.

   To ascertain  whether electricity was capable of
exciting contraction in a nerve that had not been
previously irritated, the following experiment was
made.

   Exper. 9. Twelve inches of the phrenic nerve
were measured; and  the limits of that portion
marked, by pins stuck through the  nerve.  This
portion of nerve, in its relaxed undisturbed state,
had electric shocks  passed along its substance ; but
these were found,  upon measuring the portion of
nerve,  to have  produced no  contraction in its
length.  When this portion was separated, as in
the former experiments, it contracted to 11| inches,
a diminution of £ of an inch.

   The electric fluid, in this last experiment, excited
the action of the diaphragm,  but produced no evi-
dent or permanent contraction of the nerve ;  and,
when the nature of the contraction of a nerve is
considered, it is not to be expected that permanent
contraction  can  be  ascertained  in any other way,
than by separating entirely a portion of nerve from
the rest of the system..   For the action is continu-
ed in tremors along the nerve, in quick succession ;
and, when the muscle has been excited to contract, 
148          ON THE IRRITABILITY
the complete action of the nerve is finished, and it
immediately relaxes, or returns to that state which
admits of a new action.

   This appeared to be the case in several experi-
ments made upon the nerves of frogs, and of quad-
rupeds of a higher order,  by two different metals,
as described by Galvani.   In all of them there was
a convulsion  of the muscle,  and a  tremor in the
nerve ; but, such was the rapidity of the effect, that
it could not be decided that any motion took place
in the nerve,  except what  arose from the agitation
produced by the action of the muscle.

   The experiments and observations which  have
been related appear to illustrate an action in the
nervous chords, capable of producing the symptoms
which occurred in the case related  in the former
part of this  chapter, and also those met with in
many other diseases, the symptoms  of which have
never been satisfactorily explained.

   The hypothesis  of a nervous fluid, although it
may  explain  every  symptom which  originates in
the  brain, and  from thence pervades any part of
the system, and  every symptom which  begins in
the extreme parts and goes to the brain, does not
give a satisfactory solution of those nervous agita-
tions  brought upon an extreme part, which only 
OF THE NERVOUS CHORDS.        149
proceed  for some way in the course of a nerve,
and  are  there arrested, without being allowed to
proceed to the brain.

  The circumstance of nerves having been divided,
and their functions being restored twelve or twenty-
four months after, when the two cut ends have been,
united by a new  substance, is a strong argument
against the circulation of a nervous fluid ; since no
such  effect takes place in the  pervious canals of
the body.

  In many diseases,  there are symptoms so deci-
dedly confined to  the course of the nervous chords,
that an impartial observer would be unable to ac-
count for them in  any other way, than by supposing
them to  arise  from some  action in the nerves
themselves.

  This idea must have been strongly impressed
upon the mind of Dr. Mead, who, in  treating of
his third  sort of Quincy, says, all the nerves are
convulsed,  and the patient drops  down dead sud-
denly.*

  The Tic douleureux is a remarkable instance of
this kind, both in the circumstances under which

      * Mead's Prjecepta Medica. Quarto, p. 434.
                     N 2 
150
ON THE IRRITABILITY
the spasmodic tremors  are  brought on, and the
manner in which they are propagated along the
nerve.

  In one case of this disease, in which the opera-
tion of dividing the nerve was performed, with a
view to remove the complaint, union by the first
intention did not take place ;  and, during the time
the wound was open, the inflamed state of the cut
end of the nerve made the patient liable to several
attacks of the disease, similar to those he experi-
enced before  the  operation ; but there was no re-
currence of them after the wound was completely
healed.

  This  is a very important fact; as it proves that
inflammation on  the cut end of a nerve,  while in
an irritable state,  is capable  of producing exactly
the same symptoms as the original disease.   This
effect of  inflammation upon the end of a nerve ex-
plains the startings  of the limb, which  occur too
frequently after amputation.

  These most commonly are met with when the
limb is taken off above the knee,  and the nerves
and vessels have  been previously inflamed higher
than the part at which  they were divided ; and
where the nerve is confined by the thickened state
«f the surrounding parts. 
OF THE NERVOUS CHORDS.
151
  The same fact also explains the cause of locked
jaw, when it  is produced by a wound or  bruise
upon a nerve, in a constitution either rendered irri-
table by climate,  or naturally so ; also, where the
nerve itself becomes diseased, in consequence of
the accident.

  The following case of locked jaw, from an in-
jury to  the thumb, bears so great a resemblance to
the case related in the beginning of this paper, as
to show that the diseases must be nearly allied.

  A lady of a  very  irritable habit was overturned
in her carriage, and  hurt her thumb, which swell-
ed very much ; and  the skin over the  metacarpal
bone of the fore-finger, about the size of a shilling,
sloughed off.  No symptoms came on for fourteen
days after  the  accident, when, upon bending her
fingers, violent spasms took place in the thumb,
which proceeded up  to the neck and  lower  jaw;
these were exceedingly painful, and the jaw was
so much shut, as hardly to admit a tea-spoon.  In
fourteen days  more,  the jaw began to open ;  and,
for a month longer,  there were only  two or three
spasms  daily in the  thumb,  attended  with pain;
these went up the arm to  the jaw.  At the end of
that  period the sore  on the back of the hand heal-
ed, and  she recovered perfectly from the spasmodic
affections. 
152          ON THE IRRITABILITY
  This action of the nerves likewise enables us to
understand the spasmodic affections which some-
times occur in the limbs upon which there are irri-
table ulcers.  These spasms arise from the exposed
extremities of the nerves being irritated to an unu-
sual degree; and this irritation not being confined
to  the surface  of  the ulcer,  but  communicated
along the course of the nerves, excites an action in
those chords, as high as the irritation is conveyed;
and a consequent  contraction in the  muscles to
which these nerves belong.   These spasmodic af-
fections are, therefore,  not wholly dependant on
the state of the constitution, as has been in general
believed, but are decidedly the symptoms of a local
complaint, and within the reach of local treatment,
both for their palliation and removal.

   It is highly probable, that in many cases of ulcer,
the extremities of the nerves that are newly formed
in the granulations are more under the influence of
external impressions than naturally formed parts,
and communicate their action to the nervous chords,
of which they are a continuation, producing spas-
modic affections of different kinds, which would be
immediately removed, were those sentient extre-
mities destroyed.

   The following case is in favour of  such an opi-
nion ; the  history  is  drawn up  by  Mr. Hen- 
OF THE NERVOUS CHORDS.        153
ning, the  surgeon who  had the patient under his
care.

  A gentleman, who is now 50 years old, when at
the age of 36, had a paralytic affection of the right
leg and arm, and has never acquired more than a
very  imperfect use  of  them.  Ten years  subse-
quent to this attack,  the scratch of a  cat,  on his
outer ancle, formed  an  ulcer, which healed with
difficulty.   From that time to the  present, ulcers
have often occurred on his legs, and though they
were always sluggish, yet no uncommon effects at-
tended them.   Eighteen months ago, the cicatrix
of an ulcer, just beneath the outer ancle  of the
right leg,  and two  others, in nearly the  same situa-
tion on the left leg, broke  out into sores.   These
ulcers, during six months, gave no  particular unea-
siness, but,  about  the end  of that  time, the usual
dressings  began to give pain, and this was attended
with involuntary motions of the lower limbs. Dur-
ing the following six months every  application was
used, which suggested itself to  the different sur-
geons who were consulted.  The ulcers, however,
remained  stationary,  and the contractions became
still more  severe.  Opium, which at first controuled
the spasms,  soon lost its influence.

  On the  1st of January,  1801, he  became Mr.
Henning's patient.  There was then  a manifest 
154         ON THE IRRITABILITY

difference of character in the ulcers on the paralytic
limb, from those on the other limb.  The edges
of the skin,  which surrounded the former, being
thick, prominent, smooth,  and rounded ; while
those of the others were jagged, and terminating
in an edge,  sharp, and undermined. In other re-
spects they were alike, having their surfaces cover.
ed with flakes of  coagulated lymph, which could
not be wiped off; and  a discharge of  ill-formed
pus.  Both legs were aedematous  as high as the
calf.  The most cautious touch of a probe covered
with lint gave exquisite pain, which was instantly
followed by quiverings of the skin, in  the course
of the superficial branch of the peroneal nerve.
These  were  followed by spasms  of the muscles,
the heels were drawn inwards and backwards, the
knees drawn up towards the chin ; sometimes the
patient was jerked out of his chair by their sudden
violence ; in general,  however,  these motions,
though irresistibly strong, were gradual, and gave
him time to  counteract them, by changing the posi-
tfon of his body, and grasping the chair with his
hands.  By firmly  pressing on the nerve, Mr.  Hen-
ning was sometimes able  to prevent the spasms,
and sometimes to subdue them ; but the pressure
that was requisite could not long be endured,  so
that when spasms occurred, no means were employ-
ed to resist them, and tney went off gradually, 
           OF  THE NERVOUS  CHORDS.        155

    The  ordinary number of his pulse was 78, but
  when the spasms  were severe,  it frequently was
  found to be 110.

    It seemed obvious that the spasms had originally
  been produced by the irritable state of the ulcers,
  yet the risque of increasing  their violence pre-
  cluded the use of active dressings, at least  till it
  should be ascertained, whether the sensibility of
  the nerves  might not be  blunted  by sedatives.
  With this  view, an  ointment, composed of pitch
  and sallad  oil, was  applied to the ulcers, and it
  afforded a perfect remission of the spasms during
 three days. Then its power was greatly diminish-
 ed, and soon  after the spasms recurred on the
 slightest irritation.  The balsam of Peru, extolled
 by Dr. Kirkland in this kind of ulcer, when used,
 threw the muscles into the  most  violent contrac-
 tions, and every sedative that was employed pro-
 duced the same effect.  It was therefore judged
 expedient to change the plan, but  irritating dress-
 ings were insufferable.

   Dr. Underwood was  consulted,  who proposed
quieting the  parts,  by sedative applications,  but
they all failed.  Mr. Home was afterwards called
in,  and  recommended  a trial  of  Mr. Baynton's
plan of the adhesive plaster ; under this treatment
the idcer on the paralytic leg filled  up with healthy 
156
ON THE IRRITABILITY
 granulations, which at once  put an end to the
 spasms.  But  the  plasters, though  applied with
 the nicest care, could not be  borne by the other
 leg.

   Soon after this,  a severe erysipelas  overspread
 the whole leg and foot, and two abscesses  formed;
 these  broke ; and the  sores thus  produced were
 healed by stimulating dressings and pressure : no
 spasms were brought  on  by the pain  of these
 dressings.  It  was  expected that some improve-
 ment  would have  been  derived  to the old ulcers
 from this attack, but they were not in the slightest
 degree affected by it.

   Mr. Henning,  after  so many fruitless attempts,
 was led to destroy  the  irritated  surface  of  the
 ulcers, by touching them  with a strong solution of
 nitrated silver, and to diminish  the pain arising
 from its action  by means of a  full dose of opium;
 the effects of this application  proved milder than
 those of any which had been employed, except the
 pitch.   It was therefore repeated  daily ; after the
 second  application,  a  healthy  granulated  surface
 took the place  of that  which  has  been described,
 and the discharge was converted into perfect pus.
The spasms diminished in frequency and strength,
and soon ceased entirely. 
OF THE NERVOUS  SYSTEM.
157
   On the 25th of June the patient began to feel ner-
vous twitches in his right cheek ; they were brought
on by cold, by friction, or even the touch of a finger.
This  affection is confined to the  second branch of
the fifth pair of nerves, and is evidently the tic
douleureux.   These appeared to be gradually in-
creasing upon him on the 7th of July, the time this
case was drawn  up.

   A  soldier had a  superficial ulcer, four  inches
 square,  upon the skin of the shoulder,  not going
deeper than the  cutis; this began to heal very kind-
ly, and  in the course of five days so great  a part of
it had skinned  over,  that there was only an ulcer
of half an inch square, with a tolerably healthy ap-
pearance.  At this time symptoms of lock-jaw came
on, and in three  days he died, although  there was
no other complaint whatever to bring on the lock-
jaw than this small ulcer.  If, upon the first appear-
ance of the symptoms of lock-jaw, the surface of the
ulcer  had been destroyed by  caustic, it is probable,
from the preceding case, that the disease might have
been stopped in its course, or  entirely removed.
o 
CHAPTER   VII.
 OF ULCERS IN PARTS  WHOSE ACTIONS ARE TOO
   INDOLENT TO  FORM HEALTHY GRANULATIONS,
   WHETHER THIS INDOLENCE ARISES FROM THE
   STATE  OF THE PARTS, OR OF THE CONSTITU.
   TION.

 A HE appearance of ulcers attended with indo-
lence, is the very reverse of that which was des-
cribed in  those of the  irritable kind.  The edges
of  the surrounding  skin are thick, prominent,
smooth, and rounded. The granulations are smooth
and glossy  on the surface.   The  pus is  imper-
fecdy formed, but not thin  and  watery;  it con-
sists of pus and  coagulating lymph mixed.  The
lymph is made up of flakes,  and  is with difficulty
separated from the surface of the  granulations ;  so
that when the  ulcer is wiped  clean, the coagulating
lymph adheres in  several places, giving a white ap-
pearance to these parts of the ulcer.  The bottom
of the ulcer is commonly all of the  same level,  or
nearly so.   The general aspect gives the idea of a
portion of the skin and parts underneath having been 
             OF ULCERS  ATTENDED, &C.      159

for some time removed, and the exposed surface not
having  commenced any new action  to  fill up the
cavity.

   These appearances are only met with in the truly
indolent ulcers, in which the symptoms are the most
strongly marked : in others of this species the ap-
pearances very much resemble those that belong to
the last mentioned species, when of the milder kind,
and are only to be distinguished from them by the
circumstance of mild and soothing applications being
either of no service, or even aggravating the symp-
toms, which is frequently the case.

   It may  on the first view  appear  strange that the
irritable and indolent ulcers, which are so very op-
posite in their nature, should ever have the slight-
est resemblance ; but  when  it is considered that
ulcers change their appearances very readily, accord-
ing to variations in the state of the constitution,or any
accidental circumstance which may  have affected the
parts, it will be readily comprehended.   An indo-
lent  ulcer, after any violent  exertion of the limb,
will have  more  or less of an irritable appearance.
If the patient is exposed to cold,  and kept without
wholesome food, similar changes will be produced.
Under any  temporary constitutional  indisposition 
160
OF ULCERS  ATTENDED
 the ulcer will spread, and be for a time in an irrita-
 ble state.

   It is this species of ulcer which deprives the army
 of the service of so many men, and which has, with
 too much truth, been considered as the opprobrium
 of surgery.  In the army, when ulcers from com-
 mon accidents are not attended to, the patients con-
 tinue to  do their duty in the regiment, use violent
 exercise, and are guilty of every kind of irregularity:
 under these circumstances, the ulcers soon degene-
 rate into the indolent kind, and when arrived at
 this state they are considered as  incurable.

   Many of these ulcers heal in a very short time after
 the men are  discharged, their own desire to get well
 making them give every assistance to the surgeon's
 exertions for that purpose, and the patients are -af-
 terwards met with in newly  raised corps,  in which
 they had re-enlisted.  This is a fact  within every
 military  man's knowledge, and is a sufficient proof
 that the ulcers for which soldiers are invalided  are
 by no means all of them incurable ; nor are the  men
 rendered unfit to do the duties of soldiers.   If some
 of them are cured after having arrived at the worst
 state, and after having remained  (which  they must
have done) for some  time in that condition, what 
WITH INDOLENCE.             161
 might not have been effected, had they been earlier
 put upon the right mode of treatment ?

    To this species also belong the greater number
 of those ulcers that are received into the London hos-
 pitals, more especially in men, many of which are
 cured there,  although they have perhaps continued
 for several years.

    Length of continuance alone  appears sufficient to
 give an indolent disposition to an ulcer.  It is there-
 fore immaterial, whether in its origin it was healthy,
 only attended with  weakness, or even irritable ; if
 not cured within a certain time, it becomes indolent.
 This is not, however, always true with regard to the
 irritable kind, many of which remain so, whatever
 length of time the complaint may have continued.

  An indolent ulcer may be imagined, from its name,
 and the general length of its continuance, to remain
 nearly stationary, making little or no progress to-
 wards a  cure; but this is not the case,  so great a
 degree of indolence  being rarely met with.  Such
 an ulcer is  generally forming granulations, but they
 are unable to  support  themselves beyond a very
short period;  it appears, therefore, to proceed to-
wards amendment, although very slowly,  so long as
the  granulations stand their ground ; and then, all at
                     o 2 
162
OF ULCERS ATTENDED
once, when they  are  absorbed,  the  ulcer spreads
nearly to its original size, twenty-four hours undo-
ing all that had been formed in so many days, or
even weeks.  This is a change which takes place so
constandy, and under such different circumstances,
that it cannot be attributed to any external  cause,
but must be supposed to arise from the granulations
which are formed in that indolent state of parts be-
ing unfit to answer the purpose for which they were
intended, and therefore  giving way.  It is, howe-
ver, brought on and increased by occasional causes;
as changes in the weather, anxiety of mind, or too
great fatigue.

   It is a curious fact, that there should be the same
want of powers in the granulations formed in indo-
lent ulcers, as in those attended with weakness : al-
though the circumstances seem to be so very differ-
ent :  in both, the granulations are unhealthy ; in the
one, indeed,  they are luxuriant, while in the other
they are deficient.  Every deviation from the heal-
thy action, whether it be too great action in weak-
ened parts, or too little  action in indolent parts,
equally renders them incapable of forming granu-
lations, strong enough to support themselves under
the necessary actions of the parts to which they be-
long.  Those formed in the indolent ulcer are much
weaker in their living powers than the others ; for 
WITH  INDOLENCE.            163
they are absorbed without any evident cause, their
powers of life being exhausted, and no longer able
to support them.

  That in the present species of ulcer, this unheal-
thiness in the granulations is the effect of indolence
is rendered highly probable; since in some instan-
ces it exists in a greater degree when the patient  is
perfectly quiet, and lies in an  horizontal position,
than when he is more actively employed;  the com-
mon motions of the limb rousing up the actions of
the parts, and making them approach more nearly
to those  of  health.   A bandage  moderately tight,
as it gives  a support to the muscles,  and, by com-
pressing the superficial veins, renders the circula-
tion of the blood in them less languid,  seems also
materially to assist the cure ; it admits of the limb
being  used, without  so readily feeling uneasiness
from fatigue.

  Many cases have been cured by means of a tight
bandage and exercise, after other methods of a mild-
er kind had failed.   So successful has this practice
been, that we find it recommended in all cases of old
ulcers.

  This probably carries the system too far; there
is, however, sufficient evidence to prove, that rest 
164          OF ULCERS  ATTENDED
is less necessary in cases of indolent ulcers, than in
many others.   The  good  effects of this plan may
partly arise from counteracting those of confinement
and a sedentary life, which are, to  some constitu-
tions, so extremely hurtful, as to prevent an  ulcer
from healing while the patient continues under these
circumstances.  This is very  often found to be the
case  in hospitals, particularly with patients who
have lived much in the country,  and whose employ-
ment has been in the fields ; as gardeners, and hus-
bandmen.   Soldiers are taken from various modes
of life, but many of them  must be of this descrip-
tion.

   In indolent  ulcers  it must appear, from what has
been said, that there is a backwardness in forming
granulations;  and, in those  granulations that are
formed,  a want of sufficient health  or strength to
form a complete cure.  The first of these effects of
indolence is the  only one which  has been generally
attended to  in practice ; the surgeon being satisfied
if he could in any way heal up the ulcer.   This is
a very imperfect mode, since we find, that when
they are healed by only increasing the growth of the
granulations,  without altering their disposition, the
parts will very soon give way again. 
WITH INDOLENCE.
165
  The object of our treatment should be, not simply
to produce a cure, but to render that cure as perma-
nent as possible.  This is only to be done by chang-
ing the disposition of the granulations, and render-
ing them strong enough to stand their ground, after
the ulcer is  completely filled up.   It is in this view
the modes of treatment will be considered.

   That the granulations which are formed in  ulcers
of this species differ very much, in respect to their
health and strength, according to the applications
which are used  during their growth, is sufficiendy
evinced  from daily experience.   It may, however,
be very readily demonstrated by the following easy
experiment.  Let an ulcer of six months standing,
which has acquired an indolent  disposition, have a
poultice of bread and milk  applied to it for a week ;
and at the end of that period examine the granula-
tions ; they will  commonly have in part filled up the
ulcer,  but they will also commonly be large,  loose,
and glossy in their  appearance.   If  the poultice  is
now left  off, and some  stimulating meclicine,  which
agrees with the ulcer, is used for another week, the
granulations, when again examined, will  in general
be found to have undergone a considerable change,
appearing smaller, more compact, redder, and with-
out gloss.  Where  this is  the case, it is natural to
suppose  that the ulcer healed under the last men- 
166         OF  ULCERS  ATTENDED
tioned application will be less liable to  break out
than under the former ;  the  materials by which it
is filled up being of a more healthy kind.  The truth
of this opinion is not confined to reasoning, but is
confirmed by experience.   My  own  observations
upon this subject may possibly be thought less im-
partial than those made  by any other person ; this
leads me to prefer giving the results which a gen-
tleman, who had extensive  opportunities of seeing
ulcers treated  in these different ways,  was led to
draw  from the  facts that  came  within  his notice.
He stated, at a medium, that the number of ulcers
healed under the use of stimulating medicines, which
did not break out again in a short time after getting
well, compared with similar cases'under a milder
treatment, were as four to one ;  his  remarks were
communicated to me, some  time  after they were
made, by a gentleman who consulted me as a patient.
After having stated these observations made by ano-
ther surgeon, it is proper to add, that my experience
leads to similar conclusions.

   Having so decidedly given a preference to the
use  of stimulating medicines, in those varieties of
indolent ulcers which admit of being healed by dif-
ferent modes of treatment, it will be unnecessary to
add,  that there is a very small proportion of  them
that  come under that description ; the greater  num- 
WITH INDOLENCE.
167
ber not being  sufficiently  within  the influence  of
mild dressings to admit even of a temporary cure.

  The  medicines  which have been  found  best
adapted  to promote  the cure of indolent  ulcers,
under  the different  circumstances in which  they
occur in practice, will now be  enumerated.

OF  APPLICATIONS, CONSIDERED WITH REFERENCE
           TO THIS SPECIES OF ULCER.

   1. In the form of vapour.

   Medicines in this  form are very commonly em-
 ployed in cases of indolent ulcers ; but  from the
 observations which  have now been  made, it  must
 appear that they are not such as  can promote the
 cure with advantage, nor should  they ever be ap-
 plied with that view.  Recourse  is  only to be had
 to them,  when  the ulcer,  in  consequence of  some
 accidental cause, has put on a foul appearance, and
 may be said to be in a state of temporary irritation.
 As this is unconnected with the original disposition
 of  the ulcer, and it is more  properly  during that
 period an irritable ulcer than an  indolent one, it  is
 to be treated as such till  the parts  return  to their
 indolent state. 
168
OF ULCERS ATTENDED
   It has been  found that soldiers  who have had
 ulcers  of some  standing, that were in an indolent
 state, could bear the usual daily  exercise, while in
 fixed situations, without being made  worse by it;
 but if the men  at any  time had been obliged to
 march  for several  dayrs  together, or had  been
 employed on any duty of fatigue, the ulcers put on
 so very irritable an appearance, as to give the idea
 of being  irritable ulcers  of the  worst  kind.  It is
 therefore necessary, in  forming an  opinion  upon
 such cases, to inquire into the conduct of the men
 for some days previous to the examination.

   The  patients who are received into our London
 hospitals, from having used too much exercise, and
 from excesses of different kinds, have  in general
 their ulcers in this irritated state, requiring the use
 of fomentations and poultices for  some time, before
 the  treatment necessary  for.the  cure  of the ulcer
 can be adopted.

   The fomentations in use are the decoctions of dif-
 ferent herbs, which are  supposed, from their pro-
perties,  to cleanse the ulcer, and give it a better ap-
pearance ; and it is highly probable that they de-
serve this character; but the warmth which  is
conveyed to the ulcer is, I believe,  the most material
circumstance in the application.  The decoctions of 
WITH INDOLENCE.
169
chamomile, southernwood, wormwood, and of laurel
leaves, are considered as best adapted to this state
of such ulcers. When the  ulcer is spreading,  and
very  painful, decoction of poppies alone, or mixed
with equal proportion of proof spirit, is often of
service.  The  fomentations are commonly  applied
by means of flannels,  for about ten  minutes  or a
quarter of an hour each time the poultice is changed,
which is generally twice in the twenty-four hours.

   2.  In a watery form, or in a moist state.

   Poultices  are  used with  the same view as the
fomentations,  and they may  be considered as  dif-
ferent parts of the same  mode of  treatment.  The
fomentations  are  the  occasional,  the poultice the
continued, application. Poultices  for this purpose
are  made of the same  liquors as  are   used for
fomentations ; but, for the substance of the poultice,
bread, oatmeal, or linseed meal, may be used.

   As both the fomentations  and poultices are only
intended to  bring the ulcer  into a proper state to
admit of being cured, they are  rather preparatory
steps than any part of the regular treatment  of such
ulcers.  In their common state there  is no occasion
to have recourse to these applications.
                       p 
170
OF ULCERS  ATTENDED
  In the treatment of indolent ulcers it is very natu-
ral to suppose that all medicines,  whether stimula-
ting or otherwise, will have  a material advantage
when used in a watery form, since they will mix
with the matter,  be more intimately applied to the
surface of the ulcer, and remain  in contact with it
for  a longer time; this is, however, only true with
respect to the milder applications; for to those that
are  very stimulating, no such continuance of contact
is necessary, and  were  it  accomplished,  would
probably prove hurtful, since the stimulating effects
might exceed what the parts can bear.

   As ulcers of this species require stimulating me-
dicines, there is therefore no reason for preferring
watery to  unctuous applications,  further than as
they may happen  to agree better with particular
cases.

  When stimulating applications  are used to indo-
lent ulcers, it is always to  be understood that the
medicine is only intended to  stimulate the  parts to
action ; but the actions are to be  performed by the
parts themselves, which, when once stimulated, will
proceed  to  act in consequence  of that  stimulus,
for  a considerable time after  the  immediate effect
of the  local application has  ceased.  The  stimula-
ting medicine  is therefore  only  to be  repeated as 
WITH INDOLENCE.            171
often as  is found  necessary, to prevent the parts
from falling back into their indolent state.

   It is in this way only that the effects of stimula-
ting medicines can be explained ;  such as a single
drop of tincture of opium dropped, once in twenty-
four hours, upon the cornea and tunica conjunctiva
of the eye, removing an inflammation of the eye,
although the tincture is scarcely allowed to remain
more than a second of time in contact  with  the
parts ; as the tears immediately wash it off.

   The  application  of sea water to a swelled hand
for ten minutes, once  in  twenty-four hours, will
frequently excite  the actions  of  the absorbents,
which  will  then probably continue  to act, so that
the swelling in a few days will be completely re-
moved.

   In these instances the exact time the medicine is
applied can be determined  with precision, and is
very short ; and were it longer, it would,  by being
too violent, do harm.  In other instances  stimula-
ting medicines act upon the same principle, and are
in general not much longer in immediate  contact
with the surface of the ulcer. 
172          OF  ULCERS ATTENDED
  There are indolenf ulcers which occur in patients
of debilitated  constitutions, that put on a sphace-
lated appearance, (even after they have made some
progress  towards a cure)  without any  apparent
cause, and in this way  spread to a very large size.
This unpleasant change must be the consequence of
weakness in the newly formed parts, and some in-
disposition of the general system. The varieties of
this  kind that will be  necessarily met  with in dif-
ferent patients  must  be very great ;  and among
them there will be some, which, were they classed
according to their appearances, would be generally
allowed  to belong to the species of irritable ulcers :
but as they do not recover under soothing applica-
tions, they cannot, according  to the principles that
have been laid down, be  separated from the species
of indolent ulcers,  of  which  they  appear to be an
uncommon variety.  They occur  in seamen, and
land troops which have been long at sea, and when
met with in that class of  men have been called scor-
butic ulcers.   They are  not, however,  in any way,
necessarily connected  with the  sea  scurvy,  being
but  too  frequently met  with on shore, in patients
who have never been affected by that disease.

   They are frequently  met with in the West Indies,
in soldiers who had lost their health from the  ef-
fects of  climate ; they  are not  uncommonly met 
WITH INDOLENCE.
173
 with in the London hospitals, in men whose general
 health has been impaired by the free  use of spiri-
 tuous liquors: and therefore ought to be considered
 as not belonging to any specific disease, but as com-
 mon to men  whose constitutions are greatly debili-
 tated, whether by  salt provisions, the effect of warm
 climates, or the  use of ardent spirits.

   In such ulcers a new mode of treatment has been
 very  strongly  recommended  by Dr.  Harness,
 Physician  to the  Navy,  and  one of the  Com-
 missioners of sick and hurt seamen, who found that
 the gastric juice of ruminating animals, used as an
 external application,  made the ulcer, when  in a
 sphacelated state, throw off the sloughs, and put on
 a milder appearance ; and  by a continuance of the
 same medicine the cure  was  completed.   This he
 afterwards tried in many instances, and was in gene-
 ral sucessful.

   I was naturally led, from  so favourable an account,
to make  use  of the gastric juice  in ulcers of this
 description.  It gave a good  deal of pain  on each
 application, which lasted for nearly half an hour;
but the ulcer in two days put on a better appearance,
and all the sloughs were thrown off. From  the pain
it occasioned, it must be considered as a stimulatir
application.
                      P2 
174
OF ULCERS ATTENDED
  In one case of a patient in St. George's hospital,
the gastric juice brought an ulcer of this kind into a
favourable  state, after  which  it appeared to  be
stationary; but whenever the gastric juice was chang-
ed  for  any other dressing, the ulcer spread ; and
when it was again used  resumed its favourable ap-
pearance : this happened three different times ; the
gastric juice must therefore, in this  particular  in-
stance, appear to have been  the only dressing that
agreed with it.

   The  gastric juice, as procured from bullocks or
sheep, must certainly be in a  very diluted state ; as
the liquor found in the true or last stomach, which
is the only one that contains  it, is in the quantity of
two or three pints in the ox, and two or three ounces
in the  sheep.   This practice  appears particularly
 adapted to these ulcers when they occur in seamen;
 and Dr.  Harness considers it as  equally  successful
 in the truly scorbutic ulcer.   Of this, however, in
 London there is no opportunity of making trials.  If
 this be  really the case, it  is fortunate that seamen
 are usually placed for cure in situations where the
 gastric juice  can be very  easily procured;  as the
 animals  killed  for  victualling  the navy, in the
 vicinity of the naval hospitals, afford an ample sup-
inly for daily  use.
fects  ■ 
WITH  INDOLENCE.            175
   In the West Indies, where too many cases occur
among the soldiers, bearing a resemblance to those
relieved by the application of the gastric juice, the
fresh root of the cassada grated into a pulp is em-
ployed with evident  advantage.*  This juice is a
poison, taken into the  stomach, it must therefore be
considered  as  a stimulating  application.  In this
state of ulcer, lime  juice has also been used with
great advantage.  Solutions  of   vitriol  and alum
have been recommended ; but I cannot speak, from
my own experience, at all in their favour.

   When an indolent ulcer has none of the peculiari-
ties which have been mentioned, the stimulating ap-
plications in a watery form,  that appear the best
adapted for promoting a cure, are the following.

   The  solution  of argentum nitratum, or  lunar
caustic,  is a very  useful  medicine as a local  ap-
plication, and one of  the  best in general use.   It
stimulates the granulations, and makes them put on
a more healthy appearance.  It agrees with indolent
ulcers in a greater number of patients than many
other medicines.  It has a  material advantage,  in
being capable of having its strength increased to any
degree that can be required, so as always to adapt
     '  The cassada is the Satropha Manihotof Linnaeus. 
176
OF ULCERS  ATTENDED
it to the actual state of the ulcer.  This is the more
necessary,  since  indolent ulcers, when  they  have
been accustomed to any application, which they are,
in general, very  soon, they no longer  receive  much
benefit from its  use.

   It is a curious circumstance,  that an ulcer which
at first is  unable to bear this solution of  more than
a  certain  strength, without pain, and  without the
granulations themselves being absorbed, will usually,
from the continuance of the same application for ten
days or a fortnight only,  be  able to  bear it of a
double strength, without either of these effects being
produced ; and that this increased strength will now
be necessary to  give the same  degree  of stimulus,
which had before been produced by the weaker
solution.   This  may  be considered as a proof that
 the  granulations are  become much stronger than
 they were before.

   Tincture of myrrh, either pure or diluted, which-
ever is found best adapted to the state of the ulcer,
is, in many instances  a  good application; it  rouses
up the  actions of the parts, and gives the granula-
tions a better appearance.  But where the ulcer is
very indolent, it soon loses its effects, as has been
already mentioned to be the case with many other
medicines. 
WITH INDOLENCE.
177
   The good effects  of the tincture of myrrh have
been sufficiently established, by general practice, to
give it a place among the medicines in use for indo-
lent ulcers  on the  legs ;  but  as the opinions  of
practitioners may  differ, respecting the extent of its
powers, it is right to mention the following proof,
taken from a wound of a different kind,  as it ap-
pears to be a strong evidence in its favour.

   A gentleman was cut for the  stone,  and  the
wound,  some  time  after  the  operation,  became
sloughy ;  it was so indolent  as not to throw off the
sloughs, and from the urine passing over it, the edge
of the divided skin was covered with  a crust of
calculous  matter, so that there was not the smallest
disposition  to  heal.   Several  medicines were  ex-
ternally applied, to alter the state  of the wound,
without effect; but tincture of myrrh not only  an-
swered that purpose, but under  its  use the parts
were entirely healed.

  The  tincture   of  myrrh  having  considerable
powers as an external application, led to the idea of
giving it,  in a variety of instances, internally, at the
same  time that it was externally applied, with a
view to ascertain its local effects through the medium
of the constitution;  but no  evident  benefit was
produced  by using it in this way* 
178
OF ULCERS  ATTENDED
  Decoction of the walnut-tree leaves, and of the soft
covering of the  walnut, have been strongly recom-
mended  by a surgeon of eminence in Vienna, who
states, that  its powers in  disposing foul ulcers to
heal are beyond  those of many other medicines.*  I
have used it in a number of cases  of indolent ulcers,
and  can, from  experience,  give  evidence in its
favour.

  The diluted vitriolic  acid has  been employed in
particular cases, and has been recommended  as a
medicine proper for  such  ulcers ; it has not, how-
ever, been  sufficiently  successful to bring it  into
general  use.  From my own knowledge I am un-
able to speak of it, never having seen  it used, but
have lately heard it well spoken of by an army sur-
geon, for whose opinion I have a high respect.

  The expressed juice of the pod of different  spe-
cies of pepper, in a recent  state, has been used as an
ingredient in the applications to ulcers of an indolent
kind, both in the East and West Indies.  What the
real powers of the peppers are, when externally ap-

   * Dissertatio de utilitate decocti corticum nucum juglandium
 siccatorum in tractandis ulceribus, Authore D. Joanni Hune-
 zowsky. Acta Academ. Medic. Chirurg. Vindoboniensis. Tort
 grim. 1788. 
               WITH  INDOLENCE.            179

plied in this way, I have had no opportunities of as-
certaining, nor can it be procured in this country for
trials  to be made with it.

  The peppers, given internally, have a power of
disposing indolent ulcers to heal, by exciting a de-
gree of action in  the  parts beyond what is natural
to them.   It is in this way that Ward's paste dis-
poses  slight cases of fistula;  in ano to heal ; and
makes the wound, after the operation for a fistula,
put on a more healthy appearance. The  peppers
have  been known to make a fistula in perinseo close
up. This practice may very reasonably be extended
to indolent  ulcers on the legs ; but I have  not yet
had any experience of its internal use in  such cases,
and therefore mention it only as deserving of trial.

   After having mentioned the medicines in com-
mon use  to  indolent ulcers, it is proposed to add
one which has not been before laid  before the pub-
lic.

  The nitrous acid,  diluted to  such a degree as
will fit it for an  external application,  is found, by
experience, to be  a  very  useful  medicine.   The
proportions  must be  varied according  to  circum-
stances ;  but a scruple to eight ounces of water will
in general answer.   The  best mode of ascertain- 
180         OF ULCERS  ATTENDED.
 ing the proper degree of strength for this solution
is by applying it to the tongue,  and when it stimu-
lates without being acrid, it is of a proper strength
to begin with.

   In bringing forward any new medicine, it is not
 sufficient to mention  its effects ;  it is also  proper
to state the reasons that led  to  its adoption,  so that
the grounds upon which it was  taken up may be
fairly understood.

   In considering the  different applications to indo-
lent ulcers which are in common use, I was led to
remark that three of them, on which  experience
had led me to  place the greatest dependance, had
the nitrous acid  as  one of their component parts;
the other part being either mercury or silver.   This
is the case with the  unguentum hydrargyri  nitrati,
the arg«ntum nitratum, and the  hydrargyrum nitra-
tum rubrum.   This  circumstance appeared deserv-
ing of attention, and induced me to believe,  that as
these  three chemical preparations  are applied in a
very diluted  form, they must be in part decompo-
sed ; and in  the argentum nitratum some of  the
metal is separated in form of  a  powder, before the
application is actually made to the  ulcer.   If this
is the  case, the detatched  acid  will mix  with  the 
WITH INDOLENCE.
181
water, so that the efficient part of this medicine, lo-
cally employed, must be the nitrous acid.

   Upon these grounds the effects of that acid were
tried on ulcers of different kinds.  With those that
were irritable it evidently disagreed.  In those that
were  attended  with weakness,  in some instances,
and in a very diluted state, it produced an amend-
ment ; in others, it retarded their progress ;  but in
many of the indolent ulcers it promoted,  in  a very
uncommon manner, the progress of the cure.

   The apparent effect of the nitrous acid as  an ex-
ternal application,  is different  from  that  of most
other medicines of  a stimulating nature : it dimin-
ishes the quantity of matter or pus, and instead oi
giving a healthy, florid appearance to the surface of
the ulcer, there  is a soft ash-coloured coagulum,
which partially covers the  granulations:  near the
circumference this  is more compact and harder ; it
there forms a complete crust, and firmly adheres to
the surface.  If the bottom of the ulcer  is  nearly
on the  same plane, the greater part of it has this
coagulum  spread  over it,  with small  interstices,
through which the  granulations are  seen.   If  the
ulcer is  hollow in the middle,  and gradually rises
at the edges, the crust is met with  on  the circum-
ference  or outer edges, while the  softer coagulum 
182         OF ULCERS ATTENDED
is seen within these edges, and in the centre is com-
mon pus, till it has attained  the level of the other
parts.   There is a succession of these crusts form-
ed  upon  the margin of the ulcer,  one  under  the
other :  these  crusts  bear a greater resemblance to
laminae of common cuticle than any thing else, and
the parts underneath evidently rise higher and high-
er, till they come nearly to the level of the common
skin.  When that is the case, the crusts are  longer
in separating by four or five days,  and on their re-
moval a very perfect cuticle appears  underneath;
much more so than is usually met  with in an ulcer
cicatrized by means of other dressings

   The diluted nitrous  acid gives  a good  deal of
pain on its first application, this lasts  for about  half
an hour,  and then goes off;  the pain is  afterwards
 less severe.

   In one case of a very indolent ulcer the nitrous
 acid was applied, in the proportion  of two  drams
to ten ounces of water ; it  gave little pain, and the
parts began to put on a more healthy appearance ;
but after having done so,  their sensibility was so
much  increased, that a solution one  third  of the
former strength gave pain, and was rather stronger
than the parts  could now bear. 
WITH INDOLENCE.
183
  The progress in the healing of an ulcer to which
the diluted nitrous acid  is applied, differs so much
from what we commonly meet with, the  process of
skinning is so much more rapid, and  the new skin
so much more completely formed, that it was natural
to suppose that  the medicine  produces some  very
considerable change in the  granulations,  by which
these effects are brought  about.  What this change
is, has not been  ascertained ; the only visible effect
is the coagulation of the pus as it is secreted, which
coagulum  forms  an  external application to  the
granulations, and puts them in circumstances which
appear  more favourable  for filling up parts,  and
forming new skin. This coagulated matter is thrown
off by the pus next secreted, which is also coagulated
in  the  same  way, forming  another lamina  im-
mediately in  contact with the  granulations.  The
manner in which the  granulations  increase, is hid-
den by this covering, but from their  rising higher
and higher, it is evident that the parts  are  very
active in forming them.

   Pus coagulated by the  diluted nitrous acid forms
a nidus for the granulations, which appears from the
instances  in  which it has  been tried, a better ap-
plication to them than the pus itself, or many other
medicines of a different kind.  In  a few  weeks  an
ulcer of many years standing has skinned over, to 
 !84           OF ULCERS  ATTENDED

 ilie extent of several square inches; and the  new
skin, a few days after being formed, has very nearly
resembled that of the surrounding parts.   The skin,
in various instances, has formed before  the ulcer
had been filled up completely, so that the margin of
the new skin was a  good deal  lower than the  sur-
rounding old skin ; but some weeks after being skin-
ned over, this difference of level gradually disap-
peared.

   If  the  solution is too  strong, it forms a hard
 crust over the whole surface of the  ulcer, giving it
 the appearance of being  covered by a piece of dry
 parchment.   This should  be avoided, as  the dried
 crust remains for several days, after  which it is
 separated, and the progress of the cure is impeded
 while that process is taking place ; so that  by such
 treatment an  ulcer  might be kept nearly  stationary
 for months.   If this medicine is injudiciously ap-
 plied, it will be  found to produce that  effect.

   A certain degree of indolence in the  ulcer seems
 necessary, to  admit this process to go on ; for in
some cases  the  nitrous  acid  irritates,  and makes
the ulcer  spread: and even in ulcers with which
it agrees, and which  heal very fast under its  use, if a
state of irritation is  brought on, it becomes neces- 
WITH  INDOLfiNCE.
185
Uary to leave it off, as the ulcer will then  spread by
a continuance of the application.

   In stating that the only  visible  effect  of the ni-
trous acid is that of coagulating the pus,  it is by no
means  intended  to infer that  no other effect is
actually produced.   On the contrary, there is reason
to believe that it acts upon the granulations as  a
stimulating medicine, too violent for several  species
of ulcers,  but adapted  peculiarly to such  as are
indolent; and that the  coagulation of the pus is a
chemical effect, which answers a  secondary but  a
very salutary purpose.

   Several patients with ulcers, which had the nitrous
acid  applied to them, have been allowed to .walk
about and use exercise while under that  treatment,
and   have  not  found  the progress of the  cure
retarded, although  no  bandage that could  in  any
way support  the  limb,  was applied to  it.   This,
which there is reason to belive  will be  found to be
generally true, is  a circumstance  very strongly in
favour of this application.

  In cases of ulcers on the leg,  in which there is  a
portion of bone  exposed,  which is  neither acted
upon by the absorbents, nor deprived of life so as to
form  an exfoliation, the ulcer is  prevented from
                      Q.2 
186         OF ULCERS ATTENDED
healing, under these  circumstances,  applying the
solution of nitrous acid to the bone, removes the
earthy part; and excites the absorbents to act upon
the animal portion which remains.

   By this treatment many  ulcers have healed much
sooner than they would otherwise have done.

   The effect of nitrous vapour, in destroying the of-
fensive smell generated in confined apartments, con-
taining a number of  sick people, and its power of
preventing contagion from  spreading, are very val-
uable discoveries, made by my friend Dr. Carmichael
Smyth ;  and there is a satisfaction in being thus able
to state, that in a fluid form also, the nitrous acid is
 a medicine, which is  applicable to many  cases of
 surgery, in which it  has not  hitherto  been usually
 employed.

   3. In form of powder.

   The only medicine which seems  to be adapted to
 this species of ulcer, in form of powder, is the hydrar-
 gyrum nitratum rubrum, all the others being either
 too mild, or more conveniendy used in  an unctuous
 form.  From the violence of its action, it  is fitted
 for ulcers of the most indolent kind;  but  even  to
 them, it should only be occasionally applied, unless 
WITH INDOLEWCE.
187
it is rendered less active, by being intimately mixed
in different proportions with some inert powder.

  4. In an unctuous form.

  Unctuous  applications appear to be better adapt-
ed to this species of ulcer, than  to  any other,  and
they have some advantages over medicines in differ-
ent forms, since the necessary action is no sooner
produced, and the pus, in consequence of it, secreted,
than the  stimulating application itself is  removed
by the pus from the surface of the ulcer ;  and it af-
terwards serves as an external covering, by which
the pus is confined in immediate  contact  with  the
granulations, till the next dressing.  The oil becom-
ing rancid, which is so material an objection to this
form of medicine in other species of ulcer, is of less
consequence in this ; as the medicines combined with
it are ahvays more stimulating in their nature than the
oil, even in its rancid state.

  In the treatment of ulcers, a great stress has been
laid upoa the bad effects  of exposing the surface to
the external  air, as if atmospherical air contained
something that irritated and excited  inflammation.
In the investigation of this opinion, sufficient proofs
have been established, that air has no such property j
since when the  abdomen of an animal is filled with it, 
188           OF ULCERS  ATTENDED
no inflammation takes place.   If the cellular mem-
brane of the body is  loaded with it, these parts do
not afterwards inflame. Nor do ulcers in the throat,
that must be constantly exposed to the air, heal less
kindly than those in  other  parts of a similar struc-
ture.

   It does not appear that the exposure to air is in it-
self peculiarly hurtful; but, from every observation
I  have been able to make, an ulcer does not heal so
kindly if the parts are disturbed during that process,
which they must be when much exposed.   The na-
tural easy state, is that of the granulations  being co-
vered by their own  matter; which  is  only to be re-
moved occasionally,  that means may be used to sti-
mulate  the granulations, to secrete  a  more  perfect
pus, or such as  is best fitted to cover the granula-
tions during their increase.

   According to this statement, frequent dressings,
to  indolent ulcers,  are  not only unnecessary,  but,
when the medicines  are stimulating, will do harm.
To apply a dressing once in twenty-four hours is com-
monly sufficient  ; nor should it be  done  more fre-
quently, except when the quantity of pus is too great,
which, in this species of ulcer, seldom happens. 
                WITH  INDOLENCE.            189

  The unguentum hydrargyri nitrati mixed with
the adeps suilla, in different proportions,  according
to the state of the ulcer, is one of the best applications
to this species of ulcer,  in an unctuous form, in gen-
eral use.  The  most  common proportion is one
part of the  ointment to three of the lard.   It is,
however, almost always necessary, after using it for
some time to the same ulcer, to increase its strength.

  There  is,  very commonly, to indolent ulcers, a
thickened edge, like a welt, all round ; and the skin,
to some distance from this edge, is of a darkish-red
colour, arising from an  imperfect or languid inflam-
mation, extending along the skin of the neighbouring
parts.  Such appearances are very readily removed
by the unguentum hydrargyri nitrati, and the surface
of the ulcer, which too often has an ill fornvd pus,
mixed with blood and  coagulating lymph laid over
it, under this treatment will form healthy granula-
tions;

  Upon  comparing  the effects of this  medicine,
with those of many others that are used in the form
of ointment, it appears to have more influence over
granulations, in making them become  small and
healdiy,  than  any of the rest; and,  what may be
considered as  a  natural consequence of such a pro-
perty, the ulcer healed by it is less liable to break out 
190          OF  ULCERS ATTENDED
   ►
again.   It has a material advantage also, in admit-
ting  of being  made gradually  stronger, so that the
same degree of stimulating effect can  be kept up by
increasing its strength, as the ulcer from habit be-
comes less affected by it.

   These are its beneficial effects where it  agrees;
but there are ulcers of the same kind  in particular
patients, in which it does not answer at  all,  and
must therefore be discontinued as soon as that can be
 ascertained.

   The unguentum resinae flavae, and the unguentum
 elemi, are in very general  use for  ulcers  of  this
 species ; they have sometimes the balsam  of  tur-
 pentine, or the balsam copaibae added to them, and
 they are  frequendy  applied hot,  to  increase  their
 stimulating effects,  and adapt them  to particular
 cases.  These are the  most common applications
 and their effects  are too well known to require much
 being said respecting them in this place.

   It may be necessary  to observe,  that in general
 the resins and turpentines do not seem to have equal
 powers with the  acids and metallic salts, in giving to
 the granulations a healthy appearance ; nor  do  they
 appear to give them the same disposition  to stand
 their ground  when formed. 
              WITH  INDOLENCE.            191

  This observation may not  have been made  by-
other surgeons, in the  same way that it is now stat-
ed, but the effect must have been noticed by those
who have published in favour of the hydrargyrum
nitratum rubrum, mixed with such ointments, as a
means of  rendering  the   cure more  permanent.
When these ointments are  used, the same addition
of the hydrargyrum nitratum rubrum becomes  ne-
cessary, in the proportion of a dram to an ounce;
but  to be made  a little stronger or weaker,  accor-
ding to circumstances.

   Camphor mixed with the unguentum album, or
any  other ointment, may be applied in some varie-
ties  of this species of ulcer, but not so generally as
the  other  medicines  that  have been mentioned ;
those  cases  where there  is a degree of indolent
thickening are most likely to be benefitted by it.

   After having  enumerated the different medicines
which may be used with advantage  in indolent ul-
cers, it seems necessary to state again expressly that
these medicines, in many cases, very soon lose their
effect; and that in  such instances the great art con-
sists in changing the application as soon as this  cir-
cumstance is discovered. In regulating such changes
two things are always to be kept in view ; the one,
what had been  the original state of the ulcer;  the 
192         OF  ULCERS  ATTENDED
 other, what its  present  appearance ;  by which at-
 tention it  will often be found that one ulcer, in the
 progress of the cure, may require to be treated in se-
 veral different ways  before it can be made to heal.
 This is so material a circumstance in ulcers of seve-
 ral years' standing, that it cannot be too particularly
 noticed.   There is another thing to be adverted to,
 that although the ulcer may be in its nature indolent,
 it is liable to temporary changes whenever the con-
 stitution is occasionally affected, and while  under
 that  influence is  to  be treated accordingly.  If a
 patient who has an indolent ulcer, whieh is going on
 very well under any stimulating medicine, is attack-
 ed by indisposition, the ulcer will no longer bear the
 former treatment, but requires a milder application;
 and this milder remedy must be continued till the ge-
 neral system shall have recovered itself, and then
 the ulcer will again bear more active medicines.

   5. Of bandages.

   The great advantages derived in this species of ul-
 cer from an uniform steady compression of the limb,
 is now universally acknowledged, and some mode or
 other of producing this effect is, adopted by almost
 every practitioner. Many surgeons consider a tight
bandage as the only thing necessary, and adduce a
number of instances in favour of this opinion ; from 
WITH INDOLENCE.
193
such partial evidence, however,  we are not justi-
fied  in drawing conclusions upon a subject so ex-
tensive, particularly as the individual cases vary
more, according to the constitutional peculiarities,,
than any thing immediately connected with the
ulcer.

  Where tight bandaging is employed at the same
time that other means are made use of, the bene-
ficial effects which take place cannot be exclusive-
ly attribvited to  either mode of treatment; it is
therefore proper to remark, that in all the cases
brought forward as  evidence in favour of the dif-
ferent applications that have been here considered,
no species  of  bandaging was used,  but what was
necessary to keep  the  dressings applied to the
ulcer.

  The most effectual mode of  compressing the
limb, and giving the parts an uniform and steady
support, is by means of the laced stocking: this has
been loi.g in general use ;  it was strongly recom-
mended by Wiseman more than a century ago  ;
and we must attribute to his recommendation the
adoption of it in this country, as a common appli-
cation.

  A roller of calico  or flannel applied to the whole
leg, from the toes upwards, is a very good substi-
                      R
\ 
194
OF ULCERS ATTENDED
 tute for the laced stocking, and answers very well,
 when neatly applied.  Linen does not  make  so
 good a bandage  for  this purpose, as it does not
 yield to the motions of the limb, and is with diffi-
 culty retained upon it, being apt to slip down, from
 the smoothness of its surface.

   6.  Of adhesive  plaister.

   In the  former edition  of this work, a mode of
 using the adhesive plaister as a dressing to ulcers
 on the legs was taken notice of.*

   This mode of treatment was first practised by
 Mr. Baynton,  surgeon,  of Bristol, and the cases
 published of its success were so very satisfactory,
 as to induce me to adopt it, and give it an impar-
 tial trial.

   Since that time,  experience has enabled me to
 give  ample testimony in its favour, and induces
 me to consider it as one of the  greatest and most
 useful improvements in modern surgery.

  This mode of treatment is therefore now consi-
dered under a separate head.   It  is particularly
applicable to indolent ulcers.

  * See Descriptive Account of a new method of treating
 old Ulcers of the Legs,  by Thomas Baynton, surgeon, at
 Bristol. 
WITH INDOLENCE.
195
  The strips of adhesive plaister, spread upon linen,
are to be about an  inch  in  breadth,  or  a little
broader, and long enough to go completely round
the limb,  and afterwards  return upon themselves
for about three inches, so as to keep  their hold,
and become so many firm annular ligaments ; they
are to be  so applied, that their edges overlap,
leaving no space between  them, and the surface of
the limb, thus covered, is to extend several inches
both above and below the ulcer.  The  effect of
this practice upon old ulcers with thickened edges,
where the limb is much swoln, almost exceed cre-
dibility. In a very few days  the size of the limb,
as well as of the ulcer, is greatly reduced, the un-
healthy appearance of  the granulations wholly re-
moved, and  the matter reduced in quantity, and
rendered of a better consistence.

   As the plaister is directly applied to the surface
of the ulcer,  at the same time that an uniform and
steady support is given to the limb, it is not easy
to ascertain, whether  the benificial effects arise
wholly from  the well regulated pressure or not;
but, as in practice, the cure appears to be retarded
by  having lint  or  any other  dressing  under  the
plaister, there are grounds for believing the com-
position of the plaister itself is an useful applica-
tion to such ulcers. 
196         OF  ULCERS  ATTENDED
  Since this mode of treatment has been publish-
ed, cases of ulcers have got well under my care by
its use, which were certainly not to be healed by
any other mode, that had been tried.

   The following very remarkable instance of this
kind will support the opinion just stated.

   A gentleman, aged 64, of a full habit of body,
rather a free liver, with a naturally strong consti-
tution, six feet in height, while in Gibraltar, in the
year 1769, had a small ulcer, from the bite of a
musquito, on the inside of the left leg above the
ankle ; this was several weeks before  it could be
healed, and in the following winter broke  out
again, and was a still longer time of being healed.
He went to India,  where he remained ten years,
and in that period it broke out five different times,
but was never so bad as to confine him. Upon his
return to England it was  in  the state of a small
ulcer, and the whole leg larger and harder than the
other. It was healed by means of tight bandages,
and continued well for five years.

   At this time, which was in 1785, a sore broke
out on the  opposite side of  the same leg, which
never  healed,  continuing  sometimes  better, at
others worse,  but did not  confine him from busi* 
WITH INDOLENCE.           197
 ness till the year 1796, when the pain became vio-
 lent, upon hanging it down,  and at all times the
 ulcer  was troublesome, often depriving him of
 rest at night ; since that time the ulcer remained
 nearly of the same size, the leg gradually increas-
 ing in size and hardness.  Preparations of lead
 always disagreed with the ulcer, warm applications
 soothed the sensations, but the swelling increased
 under them ; a carrot poultice was the  only appli-
 cation that was found to give much ease.

   In 1798 the patient came under my care ; the
 ulcer  at that time was four inches broad, and
 six long, the edges of the surrounding skin  thick
 and welted, and in several parts detached from the
 muscles for nearly an inch beyond the  surface of
 the ulcer, which was sloughy, and had  no appear-
 ance of healthy granulations, the discharge was
 thin, and so offensive, as to prevent his dining in
 company, the quantity was so great as to require
 dressing three times a day, the pain severe, and ex-
 tending up to the thigh ; the calf of the leg  mea-
 sured in its circumference four inches  and a half
 more than that of the healthy leg, which was full
 and strong from exercise.

  Under these circumstances the use of the strips
 of adhesive plaister was adopted ; they were ap-
plied directly to the ulcer, and the calf of the leg
                     P2 
198
Of ULCERS ATTENDED
rubbed with a liniment of equal parts of the ungu-
entum hydrargyri nitrati and  olive oil, allowing
him to use moderate exercise in his room.  On the
second dressing the appearance of the discharge and
surface of the ulcer were much improved; in seven
days the edges were on a level with the sore, the
discharge small in quantity, and the granulations
healthy.  In a fortnight he was allowed to visit his
friends, and take his usual exercise, which appear-
ed to be attended with advantage. In a month the
ulcer was only the size of a crown piece,  and the
calf of the leg was diminished two inches and a
half in its circumference.

   In this state he left town, and went a journey of
 500 miles, rode every day on horseback, and the
 ulcer continued  to diminish ;  at this time he had
 complaints in his chest, which induced his medi-
 cal attendants to wish the leg not to be healed till
 an issue was made, and the strips of plaister were
 applied  more loosely ; under  this treatment the
 ulcer again began to spread, but upon the original
 mode being resumed, it diminished  in size, and
 healed up j  the  leg also became as small as the
 other.

    The use of the adhesive plaister is particularly
 well  adapted to ulcers in the thigh, which are not
 disposed to heal, but  to spread into the cellular 
WITH INDOLENCE.
199
membrane under the skin, forming sinuses; many
of this kind occur in warm climates, and from the
looseness of the skin and muscles are very difficult
to heal.   Three instances of ulcers in the thigh,
which could not be cured in India, have healed in
a short time under this mode of treatment, the
patients using exercise all the time.
  NO directions can be given, respecting which of
these applications should be first tried in indolent
ulcers, as a great deal must depend on what had
been used before, without success ; and in all such
cases of long standing, many medicines must have
been previously employed ; the surgeon will there-
fore be guided by the history of the case, when it
 an be procured.

  The adhesive plaister, the diluted nitrous acid,
the solution of  the  argentum nitratum,  and the
unguentum hydrargyri nitrati,  are the medicines
on which it is reasonable to place the greatest de-
pendance. 
CHAPTER VIII.
 OF ULCERS ATTENDED WITH SOME SPECIFIC DIS-
   EASED ACTION, WHETHER CONSITUTIONAL OR
   LOCAL.

 LJ LCERS are met with on the legs of persons
who labour under constitutional diseases, and also
of persons who have not any universal disease,
but are in that state of body which induces parts,
when injured, to assume some diseased action.
Such  ulcers do not properly come under any of
the former heads, since they do not heal under
any of the medicines which are found to answer in
these different species of ulcer ; they are therefore
to be considered by themselves.

   When ulcers of these  species  are distinctly
marked, they neither resemble, exactly, the irri-
table nor the indolent, but may be mistaken some-
times for varieties of the one, and sometimes of
another ; there is, however,  commonly an  un-
healthy appearance of the  skin immediately  sur-
rounding the ulcer, which gives to the whole a dis-
eased aspect, not seen in common ulcers. 
          OF ULCERS  ATTENDED, &C       201

   The ulcers which take place in persons whose
 general systems are contaminated by the venereal
 disease, come more frequently under the eye of the
 surgeon than any others attended by a specific dis-
 eased action ; these are therefore mentioned  as
 having the character  of a diseased  ulcer most
 strongly marked.   Any such diseased appearance
 has  been generally considered as a symptom  of
 lues, and ulcers in which it is  assumed have been
 too often referred  to  that cause.   This has been
 productive of many serious mistakes in practice ;
 for these peculiar appearances arise from the parts
 being in a diseased state,  but are not confined  to
 one specific action, and take place  in many other
 diseases, as well as the lues venerea.

   As  ulcers which are formed on persons, whose
 constitutions are  affected by the lues venerea,  in
 general require nothing but removing the consti-
 tutional disease by means of mercury, they cannot
 properly be  said to  belong to our present subject,
 which is more particularly the local treatment of
 ulcers.  There are, however, many ulcers that
 were  originally venereal,  which after  the virus
 has  been destroyed,  assume  some new diseased
 disposition.   This may happen in different ways;
 it may arise  from the state in which  the parts
 were left by the original disease, or it may be the
effect of a long continued course of mercury, and 
202
OF ULCERS  ATTENDED WITH
in many cases a combination of both of them.  In
this view the venereal disease becomes a source of
many diseased ulcers,  some  of which  are  met
with on the legs.

  Ulcers  attended by  disease  occur also in per-
sons of scrofulous  habits, in those whose bodies
are weakened by a long  continued intemperance of
different kinds, in those disposed to cancer, and in
many instances arise from causes, with which we
are little,  if at all, acquainted. Were there any
means of  ascertaining  all the diseases of the  sys.
tem, or of the parts,  which produce  these  un-
healthy or ill-conditioned ulcers j  could they be
distinguished with any degree  of accuracy from
one another, it would be right to consider them in
 some order connected with their causes or appear-
 ances ; but this, till our knowledge of ulcers shall
 be greatly improved, cannot well  be done.  At
 present it will not  be attempted to do more, than
 to  state the  medicines  which may be  used with
 advantage in ulcers of this description :  pointing
 out, under the head of each medicine, such cir-
 cumstances as may assist the judgment in deter-
 mining which are  the most proper cases for their
 use.

   In ulcers in general, the principal dependance
 tor the cure must rest upon the local applications; 
      SOME  SPECIFIC DISEASED ACTION.    203

as the complaint, although under the influence of
the system at large, and varying in its appearance
according to the peculiarities of the general  sys-
tem, is still a local complaint; but when they arise
from a specific disease, whether it is in the system
or in the part, it is  natural to suppose, that what-
ever medicine can relieve the specific disposition,
will do it, in many cases,  with equal advantage
through the medium of the system, as when locally
applied ; and even where used  internally without
the same degree of efficacy, it must, if it acts at all,
be generally supposed to assist in the cure.
1.  OF THOSE ULCERS WHICH YIELD TO MERCURY.

  IT is not meant, as has been already stated, to
consider those ulcers which are immediately con-
nected with the venereal disease, but such only as
are produced by other diseases of the general sys-
tem, or of the parts, which yield to the effects of
this medicine.

  It was natural,  when the  beneficial effects of
mercury in  the  venereal  disease  were first dis-
covered, to suppose that every complaint which
yielded  to mercury must be venereal.   It was,
however, to be  expected  that obersations, accu- 
 204      OF ULCERS ATTENDED  WITH

 rately made, would soon ascertain that this active
 medicine is capable of producing salutary effects
 in many other diseases.  Yet a long time elapsed
 before this was generally allowed.

   Even now, when it is universally admitted that
 mercury, employed through the  medium of the
 system, is the most efficacious medicine in inflam-
 mations of the liver, and in diseases of  many of
 the other viscera, surgeons very  unwillingly give
 it credit for the cure of ulcers that are not vene-
 real ;  but are inclined to suppose  every ulcer that
 yields to such treatment arises from that disease.

  This is  by no means true ; for many ulcers, un^
 connected with the venereal disease, which re-
 ceived no benefit from other medicines, shall heal
 under a mercurial course, or yield to mercurial
 applications.  In some cases the ulcer has remain-
 ed stationary during the use of the mercury, but
 as soon as it was left off, has put on a more kindly
 appearance;  the  mercurial course  having pro-
 duced so  great a change in the  constitution, as
 to destroy the disposition which had kept the ul-
 cer from healing.

  Such ulcers are, in general, in their appearance
allied to the indolent kind, but have some diseased
disposition  peculiar to  themselves.    Mercurial 
SOME  SPECIFIC DISEASED ACTION.    205
frictions are in these cases to be preferred,  as  it h
a material object to impair the constitution as little
as possible, by leaving the stomach undisturbed, and
in a state to take nourishment.

   There are  ulcers on the instep and foot, with a
very thickened edge, and a diseased state of the sur-
rounding skin, approaching in their  appearance to
what is called Elephantiasis.  These are  frequently
met with in servants of opulent families, where they
had led an indolent life, and fed  upon a luxurious
diet.   In cases  of  this kind  fumigation  with  the
hydrargyrus  sulphuratus  ruber  has  healed the  ul-
cers, and resohed, in a great degree, the swelling of
the  surrounding parts.

   The mercurial ointment, either made by calomel
and hog's-lard, or the unguentum hydrargyri mitius,
mixed with camphor, answers, in some cases, better
than any other application.

   Camphor, in general, renders  the mercury more
active, than when employed alone ; and the mouth
has been frequently known to  be affected by an ap-
plication of this kind to a small surface, when the
mercurial ointment, applied to a much larger extent,
has produced no such effect.
                       s 
1206       OF  ULCERS ATTENDED WITH
  The hydrargyrus muriatus diluted with water (to
which a small portion of spirit has been added) in
the proportion of a grain to an ounce, is a very use-
ful application to many ulcers with a diseased as-
pect, more particularly those that are superficial,
with a thickened edge, and appear to be principally
 confined to the skin.
2.  OF ULCERS WHICH  YIELD TO THE USE OF DIF-
    FERENT PREPARATIONS OF THE C.0NIUM MACU-
    LATUM, OR HEMLOCK.

    THE  inspissated juice of the conium macula-
turn internally employed,  is by  some practitioners
supposed to be entirely inert; while by others it is
believed to have considerable powers over many dis-
eases.  From these opinions, so  diametrically oppo-
site,  and  both  taken  from actual  observation, it
would seem that its effects are very precarious.   I
confess  myself to  be  by no means  warm in its fa-
vour, for though it is  sometimes of service in local
complaints, it has  so  often failed,  that much reli-
ance cannot be placed upon it as an internal medi-
cine, in diseases connected with  surgery. 
      SOME SPECIFIC DISEASED ACTION.     207

  As an external application, the conium macula-
turn is a much more certain medicine ; and I do not
hesitate to declare myself convinced, that there are
cases of diseased ulcers on the legs which are cured
by it more readily than by other means.

  The ulcers  which  are most  generally benefitted
by it, from their appearance, would be classed with
the irritable ; but there is in the surrounding parts a
degree of thickening, which must be attributed to
some specific  diseased action.  These  ulcers  are
met with  in the neighbourhood of the ankle  joint,
and the joint itself is enlarged.' They sometimes
occur upon  the ligaments of the joint of the knee,
but less frequently.   From  their situation, and the
enlargement of the joint, they may  be suspected to
be scrofulous ; but from their sensibility they must
be  considered as an uncommon variety,  if  they
really belong to that disease.   In such diseased ul-
cers the conium maculatum takes off the pain, re-
duces the  swelling of the joint, and seems to  coun-
teract the  diseased disposition,  whatever may be its
nature.

  In many ulcers that are truly scrofulous, the ex
ternal applications of the  conium  maculatum are
productive of the greatest advantage particularly in
those attended with irritability. 
208        OF ULCERS ATTENDED WITH

  The conium maculatum admits of being employed
in three different forms, but only  two of them are
in general use.

  The decoction is used as a fomentation, which is
a very advantageous form,  in those cases which arc
attended with  pain ; since the  warmth assists in
soothing and alleviating the symptoms.

  It is  used in the form of poultice, which has an
advantage, as it admits of  being much longer con-
tinued to the ulcer.  The decoction of  which the
poultice is made should be much  stronger than is
commonly directed.   Eight bundles, or four hand-
fuls, of the dried  herb, and a  greater quantity of
fresh leaves  in  proportion, should be boiled in a
quart of water  to a pint. A poultice made  with a
weak decoction has  frequently been used  without
the smallest  benefit; but when the strength of the
decoction was  increased, the ulcer shewed evident
signs of amendment.   Where  the weight  of the
poultice proves oppressive to the limb, the decoction
may be applied upon lint to the ulcer.

  The inspissated juice of the conium  maculatum
admits readily of being  formed into an  ointment;
but although several trials have  been  made with
it, the results were not in its favour as an external
application. 
SOME  SPECIFIC DISEASED ACTION.     209
 3. OF ULCERS WHICH YIELD TO THE  APPLICATION
                 OF SALT WATER.

    Salt water is an exceedingly good application in
 many scrofulous ulcers, some  of them being more
 readily cured by it than by other applications.  The
 form of poultice  is most commonly  employed ;  but
 in many cases of ulcers on the legs,  keeping the part
 immersed in  tepid salt water,  for  fifteen minutes,
 twice a day, appears  to be preferable to any other
 mode.  Several  small ulcers  have  got well under
 this treatment in a fortnight, which had resisted the
 effects of internal medicines,  and  many different
 external applications,  for  six months ; nor did the
 ulcers return afterwards  in the course  of several
 years.  The same mode  has been  used with large
 ulcers, and frequently with success.  In scrofulous
 ulcers on the legs and feet, the salt-water poultice
 sometimes brings out pimples  on  the  skin, so that
 the application cannot be continued.   When this is
 the case, adding equal  parts of decoction of poppies
 takes off this unpleasant effect; and after the skin
 has been for some time  accustomed to the salt water
 in a diluted state, it  will bear the salt water  by
itself.
                        s2 
310
OF ULCERS  ATTENDED WITH
   In such cases the foot or leg, at the times the poul-
tice is to be changed, will receive benefit by being
immersed for ten minutes in tepid  salt water.

   In some superficial ulcers, attended with a thick-
ening  of the skin, that have been  in that  state for
months, the application of tepid salt water has pro-
duced a cure.

   When there is an unusual coldness  in the limb,
without any tendency to mortification, the tepid salt
water may be used with great advantage ; it brings
a glow upon the skin, and rouses up the actions of
the parts, so as to give an ulcer which had for some
time been in an inactive state, a disposition to heal.
These cases occur in tall thin men who are unhealthy,
and advanced in life.   They are also met with in
voung women who  are very weak and unhealthy;
the whole system in such cases is apparently  defec-
tive, not having sufficient energy to do more than
carry on the functions of life, and  being therefore
unable to support the effects of disease.

  Where the leg has a tendency  to become   anasar-
; ous, the application of tepid saltwater is sometimes
tound entirely to remove that disposition. 
SOME SPECIFIC DISEASED  ACTION.     2ll
 4r. OF  ULCERS WHICH YIELD TO THE USE OF THE
            ARGENTUM NITRATUM.

   There is a species of ulcer which does not appear
 to go deeper  than the cutis,  but spreads in  all
 directions, producing ulceration on  the surface of
 the skin, and frequently extends in depth through its
 whole thickness, or nearly so.  This diseased  dis-
 position, whatever it is, does not remain in the parts
 which have ulcerated, but only on the edge of the
 skin, where the ulcer is increasing, for the surface
 first affected heals while the skin beyond is in a state
 of ulceration.

   This  description applies nearly equally well to
 the ulcers produced by three  separate diseases, to
 all of which the soldier is peculiarly liable.   One is a
 leprous  eruption, most commonly met with among
 the impressed men brought from Ireland.   Another
 is  the consequence of buboes, which from their long
 continuance after  the venereal virus  has  been de-
 stroyed, dispose  the  skin to  take  on this disease.
 The third is a disease of warm climates, commonly
called the ring-worm.  All of these, as far as my
experience enables me  to form an opinion, yield 
 212       OF ULCERS ATTENDED WITH

 more readily  to the solution of argentum  nitratum
 applied to  them in different proportions, than to an-
 other local treatment.

   The disease met with  among the  Irish recruits
 is evidently of the leprous kind, as  it is communi-
 cated by infection ; and, in those instances that have
 come under  my  care, was received by lying in bed
 with  persons  affected  by it.   Under these circum-
 stances, a vulgar prejudice of its only affecting parts
 similar to those that had the disease, is very readily
 explained, for such similar parts in bed are the most
 likely to come in contact with each other.

   It affects in  general the breast, back, and  legs ;
 it shows itself by a swelling like a large boil, with a
 pale red margin, extending for some way all round ;
 a reddish black scale forms on the top, the boil be-
 comes extremely painful, and itches ;  the scales fall
 off, exposing a foul ulcer, which discharges a foetid
 limpid fluid,  and excoriates  the surrounding skin,
 producing ulceration wherever it comes  in contact:
 in this way it  spreads over the  greater  part of the
limb, and  in  some instances over a considerable
portion of the  body; the parts first affected healing,
while the  disease is  extending itself to those be-
yond. 
        SO.ME SPECIFIC DISEASED ACTION.     213

    These ulcers remain open sometimes three, four,
 or even six months,  and then heal  up, leaving a
 cicatrix  similar to that which  remains  after the
 small pox ; those cicatrices often break out again in
 the spring in the same way that the disease first began,
 by  forming a boil which becomes an ulcer, and
 spreads as  it did before.  In the very hot weather
 the pain and quantity of discharge are the greatest;
 so that in the month of June the disease is the most
 virulent, and in the autumn subsides.

   The symptoms  are aggravated by the  use of
 spirituous liquors, by feeding on salt provisions,
 and catching cold ; under any of these circumstan-
 ces  the ulcers are more inflamed and the pain more
 violent.

   A number of cases  of this kind came under my
 care in the year 1778, at the Naval Hospital at Ply-
 mouth, being brought from Ireland, among the men
 impressed for the use  of the navy.  Mild applica-
 tions did not answer ; more stimulating medicines
 gave relief; and the solution of the argentum nitra-
 tum appeared upon the whole to be the best adapted
to  this disease.

   The disease  in the skin produced by the effects
of  very irritable  buboes, in constitutions broken 
214
OF ULCERS ATTENDED WITH
down by mercury, is very similar in its progress to
that which has been described;  it is, however, more
violent, the ulceration going deeper than the skin,
which makes it more painful; it  spreads in some
cases down the greater part of the thigh, and up-
wards  almost round  the  body.   The  new skin
which forms is readily disposed to ulceration, and
the  parts break out again very commonly  in the
spring.  The discharge is of a  thin acrid kind ; and
as it excoriates the surrounding skin, there is little
doubt but that it  would affect the skin of another
person.

   In several cases of this kind, a  variety of appli-
 cations  have been tried, but none of them agreed
 with the skin so well as the  solution of the argen-
 tum  nitratum ;  all preparations  of mercury  did
 harm;  no unctuous application answered,  so that
 it was always necessary to return  to the argentum
 nitratum ;  and by steadily persevering in ^ts use,
 even in the worst of them, a cure was nearly effect-
 ed,  after  a continuance  of the  disease for  nine
 months, previous to its being applied.

   The  ring-worm  is  considered  as a disease  of
 warm climates ; and in the stage where an ulcer is
 formed, it certainly is confined  to hot countries ;
 it is however, met with in a less degree in the warm 
SOME SPECIFIC DISEASED ACTION.    215
season in England.  It is supposed to be infectious,
and always to be caught in that way ; that  it is so
generally, there can be no doubt,  but it also arises
very  commonly without any infection : this  how-
ever, probably happens where the  skin  is very rea-
dily affected by the disease.  That infection is not
necessary for the  production of the ring-worm, is
proved  by the following instances where   it arose
spontaneously.

   In the  summer 1779, while at Plymouth,  I was
 consulted by an officer in the 75th regiment,  at the
 desire of Mr. Venour, who was then surgeon to it,
 for a complaint on the skin of the  upper part of the
 thigh, which appeared to be an uncommon disease,
 and  did  not yield to  any applications that were
 made to it.  I felt myself equally at a loss in what
 view to consider it; mercury was used in  different
 forms, but without any good effect, and in the au-
 tumn it very gradually went off.

   About a year  after seeing this case I embarked
 for the West Indies,  and as  soon as the ship had
 got within the tropics, found myself more oppressed
 and irritated by the heat than  most of the Europe-
 ans on board, and to  my astonishment found a simi-
 lar complaint had taken  place to that under which
 the  officer had  laboured at Plymouth.   To allay 
  216       OF ULCERS ATTENDED WITH
  the extreme pain and itching it produced, cold wa-
  ter was frequently applied to the part, which kept
  it very cool; under  this treatment it went off, but
  but  not  for  several weeks.   Upon  my arrival in
  the West Indies the disease returned, aud was as-
  certained to be the ring-worm,  so common in that
  country, which it was impossible for  me or  the of-
  ficer in the 75th regiment at Plymouth, to have re-
  ceived by infection.

   The ring-worm begins by an efflorescence on the
  skin, a little raised  above the natural level, which
 spreads from a centre ;  when the disease increases
 in violence, the margin of the circle is raised into a
 welt, and the surface contained within it appeals
 scurfy ; the welt becomes covered with a scab which
 falls off, exposing an  ulcerated ring, commonly not
 more than  a  quarter of  an inch  broad ; the ulcer-
 ation spreads outwardly, and heals towards the cen-
 tre,  so that in general  the breadth of the ulcera-
 tion is nearly the same, although the circle is becom-
 ing larger and larger.  It seldom becomes of any
 depth, being entirely confined to the  cutis ;  but in
 the worst cases it appears  to extend through  its
whole thickness.   In this  stage it must be classed
among the diseased ulcers, and among  those of a
very distressing kind, as  the painful symptoms are
exceedingly violent.   The discharge is not  pus. but 
       SOME  SPECIFIC  DISEASED  ACTION.  ~   217

a  thin  watery fluid, of a very acrid nature, which,
by its virulent properties, most probably extends the
disease along the skin.

   In the East Indies, the application in use  to it, in
this  stage, is  vinegar,  saturated with borax.   The
natives employ the juice of some plants, which is
sold as a secret medicine ;  it is made by an  Hindoo
doctor at Vizagapatam, and  sold  at the different
presidences in India.   This medicine is of a very
acrid nature,  giving the patient excruciating pain,
but removes the disease in a very short time.

   The solution of the argentum nitratum answers
in the milder cases, and there is little doubt of its
being equally successful  in those that are more
severe.
T 
218       OF ULCERS  ATTENDED WITH
   >.  OF  ULCERS  WHICH YIELD TO THE USE OF
                    ARSENIC.

   ARSENIC has'been applied externally, in cases
of cancer, by a number^of empyrics,  as a caustic;
but from the violence of its effects, regular practition-
ers have in general been afraid to employ it in cases
of surgery.   It is, however, a medicine that may
be used with safety,  both internally and externally,
in many diseased ulcers, with  the  greatest advan-
tage.

  Those ulcers in which I have been led  to employ
it are named, from the virulence of their disposition,
noli me tangere ; and are very nearly allied to can-
cer ;  differing from  it in  not  contaminating the
neighbouring parts by absorption, but only spread-
ing by immediate contact.

  Ulcers  of this kind differ exceedingly from one
another in their degree of virulence ; but they are
all so far of the same nature, that arsenic  in general
agrees with them, and puts a stop to their progress,
while they are aggravated by milder dressings. 
      SOME SPECIFIC  DISEASED  ACTION.     219

  I have been in the habit, for many years, of using
arsenic externally to such ulcers, and its effects en-
couraged  me to continue this practice, but did not
authorise  giving  it internally with this view, lest
the quantity necessary to be of any service might
prove hurtful to the coats of  the  stomach.   I was,
however,  induced to  try it some  years  ago in St.
George's  hospital, in the following case, in which
nothing could be well applied to the part itself.

   A woman, 65 years of age, came into St. George's
hospital on the 15th of June, 1796, with an ulcer
on the side of the tongue, of three months continu-
ance.  It was foul, and spreading backwards to the
root of the tongue, was  extremely painful, and the
ulcer had an offensive smell.  It was out of the
reach of external  application.  Finding  no advan-
tage from the use of the extract of the conium ma-
culatum,  which was  given in large  doses, it was
thought right to try the solution of white arsenic in
boiling water. She took, at bed time,  five drops for
a dose :  this made her very sick ; next night three
drops were given, which did  not disturb the  sto-
mach ; this dose  was continued for four successive
nights, and as the stomach was very quiet, the num-
ber of drops was  again increased to five,  which
were now found to agree very well.  The ulcer was
evidently better,   and at; the end of  three weeks, 
;220
OF ULCERS  ATTENDED WITH
from the time the arsenic had been used, was much
diminished in size.  The dose was increased to six
drops ;  and, in a  fortnight more, the  ulcer  was
completely healed.   The arsenic in  this case could
not act locally, as the ulcer was not situated upon a
part of the tongue to which  it could  apply itself in
the act of swallowing ;  and if it had, the time of ap-
plication must have been too short to produce much
effect.

  The success attending this case induced me to try
the internal use of arsenic  for an ulcer  upon the
side of the nose of a  young woman,  which had
much the appearance of the noli me tangere.   No-
thing was externally applied;  the whole treatment
consisting in the internal use of arsenic ; and in the
course of a few weeks the nose was nearly healed.

  These, not being cases of ulcers on thejifiegs, may
be  considered as  foreign  to the  present subject;
but they are here introduced, with a view to justify
the internal use of arsenic in those ulcers on the leg,
which receive benefit from its external application ;
since they show, in the  most  unequivocal manner,
that such practice is in itself not only safe, but capa-
ble  of being attended with  great advantage. 
       SOME SPECIFIC DISEASED ACTION.     221

   To ulcers of an untoward appearance on the legs
 arsenic may be used, both internally and externally,
 with success.

   The cases to which this  treatment is peculiarly
 applicable are  those of  the fungated ulcer.   They
 are met with in the  calf of  the  leg, and on the sole
 of the foot, shooting out a fungus from the surface,
 which is  entirely different  from common  granula-
 tions : the new formed substance is radiated in its
 structure, the bottom of the ulcer being the  central
 point, and the external  surface  (which is  always
 increasing) the circumference.   This  fungus  is
 very tender in its  substance,  and  bleeds,  if  the
 slightest  violence is  committed  on it.  This dis-
 ease in its origin sometimes appears  like a scrofu-
 lous affection of the metatarsal bones of the foot;
 but the enlargement of the parts exceeds what com-
 monly  is  met  with  in  scrofula, ulceration  takes
 place upon the  skin, and a fungus shoots out, show-
 ing,  for  the first time, the  nature of the disease,
 Whether  such  cases are originally scrofulous, and
 afterwards  assume  this  new diseased  disposition
it will be  very  difficult to determine,  but their re-
maining for a year  before the fungus shows  itself
renders it  highly probable.   The same disease takes
place in the testicle.
                      t 2 
222       OF ULCERS ATTENDED  WITH, &C
   There  appear to be  two  kinds of this  disease,
 one which is poisonous, and capable of contamina-
 ting the lymphatic glands  in the  course of absorp-
 tion ;  the other not.   There is no mode  by which
 these two species can be distingusihed in their ear-
 lier stages ; and the first kind is not to be removed
 by this, or any other application  at present known :
 it is  therefore only in the second kind that the ar-
 senic  is capable of effecting a cure.   This medi-
 cine should, however, be used in all  cases not as-
 certained to be poisonous.

    The solution  of arsenic, which  I  have  always
  used, is made by boiling  white arsenic in water for
  several  hours in a sand  heat, and taking this satu-
  rated solution for use.  When given internally, the
  dose is from three drops  to ten ;  when externally
  applied, a dram is  diluted with lb. ij  of water ;
  and this solution is gradually made stronger, as the
  parts become accustomed to it,  till it is of double
  strength.   This solution is either applied on lint, or
  made into a poultice.

     In ulcers  connected with  diseased bone,  which
   prevents them from  healing,  the luxuriant granula-
   tions rise up round the  orifice leading to the bone,
   and require   being destroyed by some  escharotic j
   the solution  of arsenic answers this  purpose better
   than any of those in common use. 
CHAPTER IX.
 OF ULCERS ATTENDED WITH A VARICOSE  STATE
   OF THE VEINS OF THE LIMB, AND THE ADVAN-
   TAGES DERIVED IN SUCH CASES FROM INCLU-
   DING THE VENA SAPHENA IN A LIGATURE.

 vJ lcers occur in many patients, but more fre-
quently in tall people, on the inside  of the leg, just
above  the ancle.   They have their origin from
some accidental cause, and when once they take
place are difficult of cure, and almost always break
out again.

   This ulcer resembles in  its appearance  those of
 the  indolent species, rather of a mild kind ; but if
 the state of the limb is examined, it will be found
 that the branches of the  superficial  veins  which
 form the vena saphena are, many of them, preter-
 naturally enlarged,  and the vena saphena itself is
 extremely large.  It is this enlargement in the veins
 which prevents the ulcer from being healed.

   This species of ulcer is seldom very deep ; when
 it spreads, it is generally along the surface ; its shape 
  224       OF ULCERS ATTENDED  WITH

  is commonly oval, the  ends of the oval pointing
  vertically.  The edges of the surrounding skin are
  commonly neither thick nor  irregular, but are im-
' perceptibly lost in the ulcer.   The  pain which  it
  gives is seldom from the surface, for pressure does
  not increase it; but there is an aching uneasy sensa-
  tion in that part of the  leg.  This pain is  deeper
  seated than the surface of the ulcer,  and very often
  extends mp the leg in the direction of the veins ; and
  is increased to a very great degree, if the limb  is
  long kept in an erect posture.

    The ulcer commonly increasing in the  course of
  the veins encourages an opinion, that inflammation
  and ulceration in ulcers in general run along the
  internal surfaces  of the smaller veins,  which open
  upon the ulcerated part, and that this is the common
  cause of their increase.   There does not appear any
  other obvious reason why the ulceration should ex-
  tend upwards,  contrary to what happens in  ulcers
  on the leg in general, especially as it will be  found,
  in the course of these observations, that there is,  at
  that time, no disease whatever in the part itself.

    That ulcers do, in some instances, spread  in the
  course of the veins, may be illustrated in the liver,
  where the veins coming from the ulcer have been
  found to have their orifices perfectly open j the ad- 
      A VARICOSE  STATE  OF THE LIMB.     225

hesive inflammation not having united their sides
together, and the internal surface for some way ap-
pearing inflamed.

  The  enlargement of the veins  of the leg, par-
ticularly the superficial veins in middle aged  and
old people, happens  so frequently, that no one who
has attended to the subject  can be  ignorant of it.
When once this disposition in the veins has begun,
it generally goes on increasing, and the limbs be-
come less able than usual to bear  violent exercise,
or to sustain the body long in the erect posture.  This
is so often met with where there are no ulcers on
the leg, that it  must be considered  as a diseased
relaxation of the coats of  the veins, of which the
immediate cause is, at present, unknown.

  Although ulcers  on the legs, therefore, cannot be
said to  produce this enlargement of the*yeins ; yet,
when  once an ulcer takes  place in such a limb, it
seems, by  making  it weaker, to increase that dis-
position, or at least to render  the progress of the
complaint more  rapid.

  An ulcer, in whatever way produced, upon a limb
in this state of enlarged veins, is more difficult to
heal than otherwise it would  have  been; is more
liable to break out again after it has cicatrized, and 
226       OF ULCERS  ATTENDED WITH
too often cannot for many years be made to heal at
all.

   This species of irker is very  common in the
army.  I have very often seen it  in  non-commis-
sioned officers, and am led to believe that grenadiers
are, from being taller, more liable to it than the men
in the batallion  or light infantry companies.  It is
an ulcer  which  external applications rarely can
remove; and many men, on this account, are either
invalided, or,  from a consideration of their former
services, or, of some particular good qualities, are
placed in situations unconnected with the effective
strength of their regiments.   The disease in the
veins, which prevents those ulcers from healing, is
frequently brought on  by the fatigues and changes
of climate to which  soldiers are  subject,  and by
which their general health  is sometimes greatly
impaired. '

   The officers in the army, from the same circum-
stances, are  more liable to this complaint than any
other description  of men in the higher orders of
society.  In them, where  no accidental cause has
produced an ulcer, it is not noticed; and when ulcers
have been formed, they may, by great attention, be
healed, so as only to break out occasionally; which,
when it happens, is  supposed to arise from the i'm- 
      A 'varicose state  of the limb.     227

paired state of their bodily  health, being seldom
referred to the real cause.

  This species of ulcer, although difficult  to  heal,
has not been considered the opprobrium of surgery,
because in general the ulcer is  not very large, nor
is its appearance such as to alarm the mind of either
the patient or the medical attendant.  But, from its
not getting well under the use of different medicines,
it has been productive of considerable embarrass-
ment  to  the mind of the surgeon, and has taken
from him the necessary confidence in the treatment
of other ulcers, more within the influence of external
applications, so as materially to retared the improve-
ment of this branch of surgery.

  This happened to myself, and many were the
mortifications met with in my attempts to heal such
ulcers, before the peculiarity  which renders them a
distinct species was ascertained, nor was it unnatu-
ral  to draw conclusions  very unfavourable to the
healing powers of the medicines which had been
used without effect, while ignorant of the circum-
stances by which they had been counteracted.

   Cases of this  kind show, in the clearest point of
view, that we are not wholly to give up the use of
medicines, because in some cases they have not an- 
228      OF  ULCERS ATTENDED WITH
 swered, since the want of sucess most prabably arises,
 not from any inefficacy in the medicine, but from
 our misapplication of it.

   It is this  species  of ulcer, which, from  its great
 backwardness to heal, has given the idea of its being
 a natural drain from the constitution,  which it was
 improper to  dry up  ; and the strong  argument ad-
 vanced in favour  of this  opinion has  been,  that
 whenever it  was healed, it broke out again, and the
 patient was full as  easy while the ulcer was open, as
 when  it was closed, if not more.   This may at first
 appear extraordinary, but can be readily explained;
 since the pain, in such cases, arises more  from the
 distended  state of  the  veins, than from the ulcer;
 and the patient will naturally be led to use more
 exercise when the  ulcer is healed, which will keep
 the veins in a more uneasy state.

   This is the species of ulcer in which tight band-
 aging to the  leg is  particularly applicable, and roll-
 ing the whole limb, from  the  toes to the  knee, is
 found  to be  attended with the greatest advantage.
 It  is to be understood, that the tight bandaging is
 not immediately applicable to the  ulcer itself, as it
will appear that it is  immaterial  in what  way the
management of the ulcer  is conducted; and  it is
probable that the success of tight  bandaging  in ul- 
       A  VARICOSE STATE OF THE  LIMB.     229

cers attended with varicose veins, has led to the use
of compression in  other  species of ulcers, wherein
it has proved hurtful;  not being suited to the state
of the limb, which often is unable to bear any thing
tight upon it.

  Soldiers who have  the slightest disposition  to a
varicose state  of the veins, whether  there is an ul-
cer on  the leg or not, should have their gaiters so
made as to answer the  purpose of a tight bandage,
which may be readily done by having them very ac-
curately fitted to  the  leg; for this purpose those
made of woollen cloth  will answer best, as its elas-
ticity allows it to yield to the motion  of the muscles,
and always preserves an  uniform compression.

   A laced stocking is a most useful application, and
if it could be  worn without inconvenience, probably
no  other  mode of treatment  would be necessary;
but it too often happens that the patient is unable to
bear  the necessary degree of general compression
for any length of time, and therefore after using it
for some weeks, is obliged to leave it off.

  Having  found, in some cases of ulcers under these
circumstances, that  no  local treatment whatever
would produce a cure, and  that the ulcer healed un-
der the simplest applications when the laced stocking
                         u 
230       OF ULCERS ATTENDED  WITH

was used; my attention was very naturally diverted
from the consideration of the ulcer itself, to that of
the veins of the leg.

   The case which most particularly  impressed my
mind with this idea, was the following.

   A. B. a workman employed by Mr. Ramsden the
optican, had an ulcer on the leg, for which he was
admitted into one of the Royal Hospitals in London;
he remained there for  several months,  but the
ulcer baffled the skill of  the surgeon to whose care
the patient was entrusted, and he  left  the  hospital
nearly in the same state in which he entered it.   As
the uian  was a valuable workman,  Mr. Ramsden
was very solicitous about his recovery, and begged
me to give him my advice.   The man  happened to
have been standing for some time before his leg was
examined, which  gave  me an opportunity of per-
ceiving the veins to be extremely varicose, and pre-
ternaturally enlarged ; the use of the laced stocking,
was therefore advised as  a support to the veins ; to
this  he immediately  had recourse,  and  very  soon
got well, the ulcer being dressed with the most sim-
ple ointment.

  This case, with many  others,  led naturally to the
adoption of the laced stocking, not as  a general  prac- 
       A  VARICOSE STATE OF THE LIMB.   231

tice in all old ulcers on  the leg,  but  in all those
where the veins of the limb were enlarged ; it also
prepossessed me  in  favour  of  tight bandaging  in
cases of ulcers on the leg.

  On putting it to the test as a general practice, it
appeared, that there  are  many people whose legs
can neither bear the laced stocking nor a tight band-
age of any kind, and that instead of deriving advan-
tage from such applications, the ulcer,  in these sub-
jects, becomes worse; or if it gets better, the limb
becomes uneasy that the patients are obliged to leave
off the bandage.

   As an instance of the first kind, the following case
is mentioned.  A gentleman put himself under my
care for a small  ulcer on his leg,  which he had in
vain attempted to heal by the common applications.
An ointment composed of one part of the unguen-
tum hydrargyri nitrati  mixed  with three parts of
hog's lard,  was  applied to the ulcer, and the  leg
rolled as  tight as the patient could bear.  He had
no sleep all night, and the ulcer looked worse next
day.   This was  not attributed to any part of the
treatment, and  therefore it was  continued.  The
ulcer became still worse: he now mentioned that
the tight  bandage gave pain, that 15 years before he
had an ulcer on the same leg,  that Mr. Moffat  the 
232        OF ULCERS ATTENDED WITH

surgeon had bound up in the same way, and that the
effect was the same.  The  bandage was  left off,
and in a  few days the ulcer  got quite well.  Since
that  time several instances of the same kind have
occurred to me, and  indeed there are many people
who in health, cannot bear the slightest compression
on the leg.

   From these examples it is evident that no abso-
lute rule of practice can be laid down for all cases ;
the peculiarities of constitution being such  as to re-
quire being considered apart.  As, however, those
patients  who  cannot bear tight bandaging at all, are
but few, they must rather be looked upon as excep-
tions, and uncommon cases, than as affording any
argument against the general treatment •, but it does
also happen that even in those cases where the veins
are enlarged, the limb too  often cannot bear com-
pression for any length of time.

   As the tight bandage and laced stocking, the only
modes of compressing the  veins recommended to
us, and sanctioned  by  general practice, in many in-
stances cannot be adopted, and in others arc  attended
with great inconveniences,  and  consequently are
seldom uniformly complied with, it is right to con-
sider in  what other way the same effect can be pro-
duced. 
        A VARICOSE STETE  OF THE LIMB.     233 "

    The remarks which have been made upon tight
 bandaging must, be familiar to every  one who has
 considered this subject with any degree of attention.
 They  have not been stated under the idea of con-
 veying any new information ; on  the contrary, they
 are rather  meant as a justification of my not having
 been satisfied with that practice in all cases.  They
 show,  at the same time, that it had not been passed
 over, but had a fair trial given it;  and after a careful
 investigation of its effects, it had been given up, and
 the failures which occurred had led me to endeavour
 to find out a substitute, which might  be free from
 its disadvantages.

   In considering the mode  by which the  varicose
 veins prevent an ulcer from healing, it appeared to be
 most readily accounted for in the following manner.
 That in consequence of the size of the vena saphena,
 and its numberless  convolutions,  the return of the
 blood from the  smaller branches is  so  impeded, as
 to retard the circulation in the smaller arteries, and
 to  interfere  with  their action in forming healthy
 granulations. This observation is, in some measure,
 confirmed by the following circumstance.   In cases
 of ulcers attended with weakness, on the lower part
 of the leg, the granulations while the patient lies in
an horizontal position, appear  florid  and healthy;
but if he is made to  stand up, and continues in that
                     u  2 
234
OF ULCERS  ATTENDED WITH
posture only for a few minutes, they become of  a
deep dark-red colour, and frequendy bleed.   This
change can only arise from the increased resistance
which the blood encounters in its return through the
veins of the limb, when the body is erect.

   An enlargement  of the  veins  produces also
another effect.  The coats  of the vessels and the
valves become thickened, which renders the valves
less pliant, they do not occupy the whole area, and
therefore are no longer of any use ; and from this
defect the whole length of the column of blood in the
vena saphena is, in the erect position, pressing upon
the contents of the smaller veins, so as to dilate them
still more and more, and keep the limb always in a
weak state.

   Under these circumstances, it appeared to be an
object of no small importance to  take off a part  of
the pressure of this column of blood, which would
probably allow the parts lower down to be in a more
easy  state, and better able to recover themselves;  it
might also prevent  the veins from being still more
dilated,  and so far stop  the  progress of the disease
in these vessels.

   The only mode of doing this, that suggested  it-
self, was that of making an artificial valve, by pass- 
      A VARICOSE  STATE OF THE  LIMB.     235

ing a ligature  round the vena  saphena, as it pas-
ses over the knee joint, and obliterating the vein at
that part.   The reason  for  applying the ligature
upon  this particular portion of the vein is,  that just
at that part the branches from the different parts of
the leg unite and form a common trunk, and as it is
the preternatural enlargement of some, or all these
branches, which constitutes the principal part of the
disease, the most effectual mode of taking off the
weight  of the  column of blood contained in the
common trunk will be by obliterating it, as near as
possible to the termination of those branches into it.

   The  practice of taking up veins  is not new ;  it
was in use by  the older surgeons in cases of vari-
cose veins,  and in one case was practised by Mr.
Huntsr.   In that particular  case  several  branches
were  separately taken up, which  increased the pain
of the operation, and  made it more tedious ; but
the man was much benefitted by it. In that instance
this mode  of treatment was adopted with  the view
of  alleviating  the  disease in  the  smaller  veins,
without any reference to the cure of ulcers on the
leg:  and  in the practice of the older surgeons, if
'he dilated branches only were  taken up,  it could 
236        OF ULCERS ATTENDED WITH

not succeed. Its  failure was  probably the cause of
its falling into disuse.*


   The  present  intention, as well as the mode  of
effecting  it, is  somewhat different.   The principal
object is the healing of the ulcer ; and this will be
found of  no small consideration, when it is known
that ulcers of this description, although not so pain-
ful and troublesome as  ulcers in common, are at-
tended with an uneasy sensation in the course of


   * " The cure ofthese-ulcers with varix is either real or pal-  '
 liative. The real  or perfect cure proposed by the ancients, I
 have delivered in the chapter of a simple varix : it is by mak-
 ing an incision in the skin, and taking up the vein, and tying it,
 &c* But this way hath not been admitted (to my knowledge)
 amongst us; nor have I often seen that a varicose ulcer could
 be cured by cutting off the branch leading to the ulcer, there
 being commonly more veins concerned in it." Wiseman's Chi-
 rurgical Treatises, octavo. Vol. 1. page 325.


 * The following is the  passage referred to in  the preceding
 quotation:

   " In simple varix, according to the ancient practice, you are
 to proceed by section, dividing the skin, and separating the
 teguments; and having raised the varicose vein, you are to pass
 a ligature above and another beneath  it, making a delegation
 of them ; then slit the vein, cast out the gross blood, and af-
 terwards digest and heal it as is after  said in an aneurisma "
 Vol. I. page 108 
       A VARICOSE STATE OF THE LIMB.     237

 these dilated veins  which disables the patient from
 bearing fatigue, this uneasiness being much increas-
 ed by standing long,  or walking.   That  these
 symptoms are peculiar to ulcers in this state of the
 limb  is evident, for  within a  few hours after the
 vena saphena has been taken up, the symptoms dis-
 appear, and the patient  is led to take notice of the
 distress it before gave  him, and to express his sense
 of the suddenness of its removal.

   Another object is  to  prevent an increase of the
 dilatation of the veins of the  limb ;  which, when
 nothing is done to  prevent it, are constandy grow-
 ing larger ; and after they have arrived at a certain
 size, become very painful on the smallest exertion,
 or continuing long  in  an erect posture, even where
 there is no ulcer.

   The mode of practice, which is now brought for-
ward,  had  been  followed for five years, when the
first edition of this  work was  published ; and du-
ring that period opportunities had occurred of see-
ing its effects in twelve different instances.  All the
cases,  except the first, were under  my care  in St.
George's hospital,  and many of the patients sub-
mitted to this  mode of treatment, from seeing the
good effects of it upon  others.   Since that time my 
238       OF  ULCERS ATTENDED  WITH

opportunities of seeing its effects, have been much
increased.

   As every thing connected with the operative part
of surgery carries along with it a certain degree of
dread to the mind of the patient, any mode of treat-
ment, however tedious, and even uncertain, is pre-
ferred by many to an operation ; although the suf-
ferings," when justly  estimated, are too often ten
 times greater in obtaining a cure without such ope-
 ration, than with it.  Under this prejudice, the ope-
 rations of surgery must continue while they are con-
 sidered abstractedly; but when the diseases for the
 relief of which they are performed are taken into the
 account, and the  pain and distress  of the one is ba-
 lanced against the other, the prejudice will be re-
 moved ; and what, upon a superficial view, was con-
 sidered as cruel, will be found  to  be humane. The
 surgeon therefore, who discovers an operation by
 which a distressing disease is removed, should be
 viewed in the. same light as any  other benevolent
 man, who prevents or removes the sufferings of a
 number of his fellow creatures.

   The  operation of taking up the vena saphena is
 extremely simple, may  be  performed in  a very
 short time, and is attended with less pain, if we may
 judge from  the account of those  on whom it has 
      A VARICOSE STATE OF THE LIMB.     239

been performed, than it would bcnatural to expect.
My attention  has been  directed in every  case in
which it has been performed, to  render it as little
painful as possidle,  and the mode which appears to
me the least so, is the following.

   As the veins are only turgid in the erect posture,
the operation should be performed while the patient
is standing; and if  placed on a table, upon which
there is a chair, the back of the chair will serve him
to rest  upon,  and he will have  the knee  joint at a
very  convenient height for the  surgeon.   The leg
to be  operated upon, must stand with the inner ankle
facing the light, which will expose very  advan-
tageously the enlarged vena saphena, passing over
the side of the knee joint. While the patient is in this
posture, if a fold  of the skin which  is very loose at
this part, is pinched  up transversely, and kept in
that position by the  finger  and thumb  of the  sur-
geon on one side, and of an assistant on the other;
this fold may be divided by a pointed scalpel pushed
through it with the back of the knife towards the
limb, to prevent the vein being wounded; much in
the same way that the skin is divided in making an
issue.   This will expose  the vein  sufficiently, but
there  is commonly a thin membranous  fascia, con-
fining it in its situation; and when that is met with,
the vein had better be laterally disengaged by  the 
240
OF ULCERS  ATTENDED WITH
point of the knife.  This is most expeditiously done
by laying hold of the fascia with a pair of dissecting
forceps,  and  dividing it; for it is difficult to cut
upon parts which give little resistance,  and there is
a risk of wounding the vein.   After this, a silver
crooked needle, with the point rounded off, will
readily force its way through the cellular  mem-
brane connected with the vein, without any danger
of wounding  the vessel, and carry a ligature round
it.   This part,  or indeed what may be considered
the whole of the operation, being finished, the patient
had better be put to bed, so as to allow the vein  to
be in its easiest state before the ligature is tied, and
then a knot is to be made upon the vein; this  gives
some pain, but it is by no means severe.   The edges
 of the  wound in the skin are now to be brought
together by sticking plaster, except where the ligature
passes out, and a compress and bandage applied, so
as to keep up a moderate degree of pressure upon
the  vein, both above and below the part included, in
 the  ligature.  The inflammation, in general, is very
trifling; it does, however, in particular cases, extend
 for  some way in the course of the veins under the
the  skin ; but even where this has happened in the
 greatest extent, it has been attended with no bad con-
sequences.   The  ligature  comes  away  about the
ninth or not later than the twelfth day, after which
the  parts commonly heal up. 
A VARICOSE STATE OF THE LIMB.    241
   As it answers no good purpose for the ligature to
 remain so long, and only protracts the cure, I have
 been in the habit of removing it on the  fifth day,
 which saves the patient five or six days of con-
 finement.  The mode  of removing the ligature is
 very simple ; the vein is so near the skin, that the
 knot is readily brought into view,  and the ring of
 the ligature, which at the time of the operation was
 filled up by the  vein, is now become loose, its con-
 tents  having been considerably  diminished  by
 absorption, so that the point of a pair of scissors can
 be readily passed through it, by which it may with
 ease be  divided,  and the whole of the ligature
 brought away.

   Cases occur  in which there is a  smaller vein
 running parallel to the vena saphena.  This, when
 the vena saphena has been taken up, afterwards
 becomes enlarged, and continues the disease; when
 that is the case, this vein also  must be taken up.
 These circumstances ought  to  be attended to in
the first examination of the disease, as sometimes
the two veins are so close together, that they may
both be included in the same ligature.

   This enlargement of the vena saphena is some-
times combined with an enlargement of the bench-
es of  the vena saphena minor,  or posterior,  that
passes up  behind, between  the two hamstrings • 
242     OF  ULCERS  ATTENDED WITH

when this is the case, the disease is in an uncom-
mon  degree of violence, and in such instances
would be  less likely to be attended with  success,
unless both venal trunks were taken up.

   In two or three cases there has been an  enlarge-
ment of the branches of  the vena saphena minor,
without the vena saphena itself being at all affect-
ed ; the principal convolutions of the  enlarged
veins were on the calf of the leg, and on the out-
side of the  foot, just below the outer ankle.  In
these instances there was no ulcer, and therefore
no very forcible reason could be urged to induce
the patients to undergo an operation, nor was there
the  same chance of success, the  use of a laced
stocking was therefore recommended ; and in case
that should not answer, it was explained to them,
that they had it in their power afterwards to have
recourse to taking up the venal trunk.

   The  enlargement  of the  vena saphena minor,
is rather mentioned  as an uncommon occurrence,
than as a case to be relieved by surgical treatment;
that when it is met with, it  may be distinguished
from the enlargement of the  vena saphena, the
subject under consideration.

   In one case where there was an  ulcer, and only
the branches of the vena saphena minor enlarged; 
      A.  VARICOSE  STATE OF THE LIMB.    243

the ulcer was situated  more  posteriorly than is
usually met with, and the branches upon the calf
of the leg were in an extremely varicose state,
forming  large projections,  the trunk itself was
very large, while the vena saphena was nearly of
its natural size.  The patient was a young woman
of a very delicate constitution, but in good health;
she was twenty-five years of age, and suffered so
much pain in the ulcer,  and in the course of  the
enlarged branches, as to be  unable  to walk or
stand for any length of time, unless the limb was
supported by bandage.

   As instances occur, in which,  though the im-
mediate  branches of the vena saphena are affect-
ed, the  disease  extends no  farther;  and as the
same thing happens, though  less frequently, to
the branches of  the  vena saphena minor ; and in
other cases, the  disease is found  to take place in
both, it becomes  necessary to explain in what man-
ner complicated  cases may be distinguished.

   The branches  of the veins,  passing up  from the
foot  to form these  two venal  trunks, anastomose
very frequently and freely with each other ; it is
therefore impossible to  say precisely to  which of
them the collateral branches belong. 
244       OF ULCERS ATTENDED WITH
  When the  vena saphena becomes enlarged,
many of the common branches, and some of those
belonging to the posterior trunk, will consequent-
ly be affected; and vice versa, when the vena sa-
phena minor is enlarged.  This, however, is not
to be  considered as implicating both veins in the
 disease, for  the branches  of one of them are
 only affected in a secondary way  by their connec-
 tion  with  the other.   Whatever number of the
venal branches of the lower part of the limb is en-
 larged, if this enlargement in those of the upper
 part of the leg only extends in the course of one
 of the venal trunks, the disease  should be refer-
 red to that trunk, whichever it is, as it is evident
 that the other, from its remaining of  the natural
 size, can have had no part in the disease. 
A VARICOSE STATE  OF THE LIMB.    245
                 CASES

OF THE VENA  SAPHENA INCLUDED IN A LIGA-
   TURE,  TO PROMOTE THE CURE OF ULCERS ON
   THE LEG.

   AS this  operation is a new one, so far as it is
performed for the purpose of disposing ulcers to
heal, the mode which appears to me the most un-
exceptionable, of laying the facts ascertained re-
specting it before the public, is giving a plain nar-
rative of the  several cases which have come under
my care ; that they may become documents upon
this subject.
x 2 
246      OF ULCERS ATTENDED WITH
                  CASE I.

  A MAN, sixty years of age, had for many
years gained his livelihood by going on messages,
having been rendered unfit for more laborious
employment by a large ulcer on the left leg, just
above the  inner  ankle.  The complaint was of
twelve years  standing;  it had been sometimes
much better than at others, but had never been
well during the whole of that period.

  In the year 1792, it became so bad as to confine
him entirely.   It was at this time I first saw him.
Upon examining the  limb, the veins were ex-
tremely large  and varicose, and the trunk of the
vena saphena, at the knee, appeared almost the
size of the little finger.   The size of this vein led
me to the idea of taking  it up  at that part, witha
view of relieving the lower branches from the
pressure of the blood, which appeard to be the
cause why the parts remained weak, and the ulcer
could not  be healed.  My opinions upon this sub-
ject  were  explained to  the patient, and  if he
thought it worthy of trial, he was told of my rea-
diness to do it for him.  The man's desire to get
well was such as  to induce him to embrace the 
      A VARICOSE STATB  OF THE  LIMB.   347

offer of any mode of treatment which afforded
the smallest chance  of a cure.  The vein was
taken up in the way that has been mentioned.  He
complained of very litde pain,  no improper de-
gree of inflammation was brought on by the ope-
ration, the ligature came away in nine days, and
in fourteen days the wound was  healed.

   The ulcer  upon the leg was  dressed with dry
lint;  it put on a better appearance on the second
day after the operation ; on the  fourteenth it had
diminished in size one half, and in twenty-eight
days was completely healed.  He was also freed
from a pain in the course of the veins of that leg,
to which  he  had been subject  for many years,
whenever he used any exercise.

   He returned to his business of carrying mes-
sages, and called  upon me a year after, perfectly
well; his leg having continued sound. 
248     OF ULCERS  ATTENDED WITH
                  CASE  H.

   Sarah Stapleton, a cook and housemaid, aged
twenty-one years,  in January 1794, was admitted
a patient into St. George's hospital, on account of
an ulcer upon her  leg.  The ulcer was  situated
upon the inside of the leg, a little above the inner
ankle,  had been of several months continuance,
and was extremely painful, more particularly so
at night, depriving her of rest.  The pain was not
confined to the ulcer, but seemed to run up in the
course of the veins ;  this was much increased
after fatigue, or having been obliged to stand for
any length of time, and consequently was great-
est at night,  after  the  labour  of the day, which,
from the nature of her situation, was very great.

   On examining  the limb, the branches of the
vena saphena were found to  be much enlarged
and varicose.  Under these circumstances it was
proposed to  make a ligature  upon the vena sa-
phena.  In performing the operation, which was
done in the erect posture, she complained of great
pain in  the  ulcer, from being obliged to  stand
firmly on that leg;  but as soon as the ligature was
tied round  the  vein this  pain ceased, and never 
      A VARICOSE STATE OF THE LIMB.    249

afterwards returned.   In the time of the opera-
tion a smaller vein was observed running parallel
to the vena saphena, which afforded a reasonable
suspicion that the disease might recur : as, how-
ever,  this was  uncertain, the  circumstance was
only mentioned, and it was left to herself to deter-
mine whether she would have it taken up at that
time,  or take the chance of its enlarging, and
whenever it did so, have a repetition of the opera-
tion.  She preferred the last.  The ligature came
away in ten days, the  ulcer on  the leg healed up
entirely in three weeks, and she was discharged
from the hospital perfectly well.

   She  went  again to service,  in  the  capacity of
cook, in a small family ; and from the nature of her
business was much exposed to the fire, and obliged
to stand a great deal, which made the veins of that
leg swell and increase  in size ; but the leg con*
tinued sound, and she had no return of the pain.
Fifteen  months  after the vena  saphena had been
tied, a vein in the place where  the ulcer had for-
merly been situated burst, and bled freely j it stop-
ped, however,  of itself; the quantity  of blood
which  was lost alarmed  her  considerably, and
made  her return to the hospital for advice.

  Upon examining the vena saphena,  at the part
where the ligature  had  been applied, two  very 
250      OF ULCERS ATTENDED WITH

large veins were discovered ; so that there must
have been, at the time of the operation, two small
branches, one on each side of the vena saphena ;
one of these only had been observed at the form-
er examination.  These two veins were now in-
cluded in one ligature.  This was done April 17,
1795.   Tying the  veins gave considerable pain,
which did not entirely go off for two days, and
then subsided ; on  the  22d,  the ligature was re-
moved,  after which the parts were much easier,
and in a week the wound healed up.

   The ligatures which are applied to secure ves-
 sels in  all operations,  while they remain in the
 wound,  act as extraneous  bodies, and keep up a
 degree of irritation, which, although it differs in
 almost every two patents, is  generally considera-
 ble :  this is known by the relief the patient expe-
 riences  after their  removal.  The leg for a time
 gave the feel of weakness, and swelled when walked
 upon for a number of  hours ;  but this gradually
 went off, and by the beginning of May, she left
 the hospital.

   The swelling of  the leg for a few weeks after
 the operation, is a symptom which occurred in
 several instances. 
A VARICOSE  STATE  OF THE  LIMB.    251
                 CASE III.

  A man, sixty years of age,  in  the year 1794,
was  admitted  into St. George's hospital,  on ac-
count of an ulcer upon his leg,  of many years
standing.  It proved to be one of those attended
with large and varicose veins ;  the connection be-
tween the two complaints was  explained to him,
and it was proposed to take  up the vena saphena,
which  he readily consented to have done.  In
this  case  the  vein was strong in its  coats, and
rolled more loosely in the cellular  membrane than
it had been found to  do in  younger patients.   It
was  readily included in a  ligature.   The ulcer,
immediately after the operation, put on a more
kindly appearance ; it healed more slowly than in
the two former cases.  This probably arose from
the man's age ; but in a month's time it was per-
fectly well.   It is to be remarked, that no dress-
ings were  made  use  of,  in  this or any of the
other cases, but dry lint and white ointment, un-
less  they are particularly mentioned. 
252      ©F ULCERS ATTENDED WITH
                  CASE IV.

   Richard Pinkley, thirty-four years  old, had
complained of a swelling of one of his legs for ten
years, during the latter part of which period,  the
veins had gradually enlarged,  and an ulcer had
broke out a little above the inner ankle, which
healed up, but broke out again.  This happened
several  times; and at  last the ulcer became so
large and painful  as not  to admit of being healed,
which induced him to  become a  patient in  St.
George's hospital.  He  was admitted under my
care, and the operation  of taking up  the  vena
saphena was proposed as the only means of making
the leg continue sound.   To this he readily acce-
ded.  The operation was performed on  the 10th
of April, 1795.   The vein was very large, and on
the third day a swelling came upon the leg; on the
sixth the ligature was removed, the inflammation
increased, and extended itself in the course of the
venal branches.   It was evidently of the erysipe-
latous kind ; it also spread up the thigh,  and the
ulcer put on a  foul appearance ; on the tenth, the
inflammation began to subside ; on the twelfth it
was still more diminished, but the swelling  re- 
      A  VARICOSE STATE OF THE LIMB.    253
mained the same ; the ulcer now put on a better
appearance.  On  the eighteenth the inflammation
was  very much  gone off;  and by the twenty-
eighth day, from the operation,  the man was per-
fectly well.

  The erysipelatous inflammation which attacked
the leg and thigh is to be considered, in some mea-
sure,  as accidental, and not  connected with  this
particular operation ;  it is very frequently  met
with in all hospitals, and in the spring of the year
we find, at St. George's hospital, that a great num-
ber of the surgical patients are liable to it, whether
their complaints arise  from accident, operation, or
ulcers of long standing.   It appears to be occa-
sioned by some peculiarity in the state of the air
at that season of  the year; and when the erysipe-
latous inflammation had once begun,  the irritation
from the ligature would direct it along the course
of the vein. 
254      OF ULCERS ATTENDED WITK
                   CASE V.


  A man, sixty years  of  age, whose business was
that of  an  out-door porter to a banking house, in
June, 1794, came into St.  George's hospital with an
ulcer upon the inner side of the right leg, of sever*!
years standing.  This  ulcer had been repeatedly
healed,  but always broke out again ; and, at the
time when he came into the hospital, rendered him
unfit to bear the fatigue of his business.   The veins
of  the limb were much enlarged, and consequently
extremely  varicose.  It was  proposed  to tie the
vena saphena, to which he assented.  The operation
was attended with little pain, and the ligature came
away the ninth day after the operation, and on the
fourteenth  the wound was  entirely healed.   The
 hospital now disagreed with his general health ;
 this he attributed to the confinement, and the want
 of his usual exercise, having been accustomed to be
 much  in the open air.  He lost his appetite ; and
 the ulcer  on the leg spread to a considerable size.
 Under these circumstances he was moved into pri- 
      A VARICOSE STATE  OF THE LIMB.    255
vate lodgings.  As soon as he left the hospital he
began to recover, and, in  less than six weeks from
the time of  the operation, the ulcer on the leg was
entirely  healed, and he was discharged cured. 
256     OF ULCERS  ATTENDED  WITH
CASE VI.
   Anthony Kennedy,  a footman, aged thirty-five,
 in the year  1793, about the month of  April, found
 that the veins of his left leg had become unusually
 large; they continued to increase in size, and in six
 months an ulcer broke out just above the inner an-
 kle.  This ulcer spread, and in eight weeks was so
 large and painful, that he was obliged to leave his
 place, and go into the infirmary at Dumfries, where
 he  continued five months; during which time his
 leg got quite well.   He returned to his master, and
 went with him  to Bath, where the ulcer broke out
 again.  The veins of the right leg began to enlarge
 in the same way, and an ulcer broke  out upon the
 same part of that leg.  For these two ulcers he was
 under the care of several surgeons of eminence in
 Bath for five months, without receiving benefit: he
 then went into  the  Bath infirmary, and was there
 six months, and both the ulcers got  well; but in
two months time they both broke out again, and
were more  painful than they had ever been before.
He was  now received into the Bristol infirmary, 
      A VARICOSE STATE OF  THE LIMB.    257

and continued there six months ;  the ulcers, how-
ever,  could  not be again healed;  and he was told
by the  surgeons, that  their not being able to heal
them  was of no consequence, as they would break
out again; and therefore he could not have a per-
manent  cure.  Under these circumstances he came
to London, and applied to me for assistance ; by my
advice he became a patient in St. George's hospital,
where he was received on the 5th of February 1796.

  At this time there  was an  ulcer on  each leg,'
which had a foul appearance ; the branches of the
vena saphena of both legs were very much enlarged
and varicose.  It was explained to him that the ul-
cers were prevented from healing by this enlarge-
ment of the veins ; and it was proposed to take up
the vena saphena of each leg, assigning the reasons,
and describing the advantages which might be ex-
pected.   He very readily  consented to have any
thing done which was  thought necessary;  and on
the 9th  of February the vena saphena of the left leg-
was taken up.  On the 16th the  ligature was re-
moved,  the wound had a very healthy  appearance,
and the ulcer was evidently better.  On the 19th,
the vein of  the right leg was treated  in  the  same
way,  and the ligature was removed on the 23d. He
felt very little pain in either limb during the opera-
                      Y 2 
258      OF  ULCERS  ATTENDED  WtTH

tion,  and had  none  afterwards.   The  ulcers,  to
which the only applications were dry lint and simple
ointment,  made a  very rapid  progress  towards
healing.  On the first of March, the wound made
in the first operation was healed,  and on the eighth,
that made by the second had also healed.   On the
26th, the  ulcer  on  the left leg was skinned over,
and that on the right leg nearly so ; this last, how-
 ever, was a  fortnight longer  before  it healed.
 About the 14th of April he  was discharged from
 the hospital. 
A VARICOSE  STATE  OF THE LIMB.     259
                  CASE VII.


  Robert Bradbury, nineteen years of age, a gentle-
man's servant, was  admitted into St. George's hos-
pital June 23d, 1796, with an ulcer upon his left leg.
The following is the history of the case.  The veins
of that leg  had been enlarged for many years, but
he had felt no great uneasiness  from  this circum-
stance till a year and a half  before ; when,  in con-
sequence of a  kick upon that leg,  just above the
inner ankle, an ulcer took place, which healed and
broke out again.  This happened several times, and
at every  return it put on a worse appearance, and
was  longer  in  healing;  and, at the time when he
came to the hospital, it was not at all disposed to
heal.

  Under these circumstances the state of the veins
was considered as the cause of the ulcer remaining
in an indolent and unhealthy state,  and it was pro-
posed to take  up the vena saphena, as a means of
producing a permanent cure.   On the 26th of June
the operation was performed, on the 30th the liga-
ture was removed.   On the  4th of July the veins 
260       OF ULCERS  ATTENDED WITH

were evidently diminished in size, and the ulcer on
the leg was entirely healed.   On the 8th the wound
made in taking up the vein was so nearly well as to
be of no consequence, and he was allowed to leave
the hospital, and return to his master.

   Five months after there had been no  return of
 the  ulcer. 
A VARICOSE  STATE OF THE LIMB.    264
                 CASE  VIII.


  James Peasnell, a footman, twenty-eight years of
age, had an ulcer on  the inner ankle of the left leg,
for twelve weeks, with a varicose state of the branch-
es of the vena saphena of that leg.  This he attribut-
ed to the cramp, a»d thinks that the veins began to
increase sixteen years ago.  This enlargement of
the veins had given him no  pain, unless they were
much pressed, or when he  was carrying a heavy
burthen.  He was admitted into St. George's hos-
pital, under my care, on the 9th of October, 1796,
for the purpose of having the vena saphena taken up
by ligature, with a view of making the ulcer heal,
and relieving the uneasy symptoms produced by  the
enlarged state of the veins.

  He had been a patient in the hospital a month be-
fore, but no mode that was adopted succeeded in
disposing the ulcer  to  heal, which induced him to
apply for this mode of procuring relief. On the 10th
of October the  operation was performed; on the 
262 '
OF ULCERS  ATTENDED WITH
14th, when the veins were pressed by the  finger,
they did not give the same pain he had formerly felt,
and the ulcer on the ankle had  a better appearance.
On the seventh day the ligature was removed, and
the wound superficially dressed.  On the ninth day
he had an attack of fever ; on the tenth was rather
better: but an erysipelatous inflammation came upon
the wound, and extended down the leg, in the course
of the cellular membrane :   but  the branches of
the vena  saphena were  not affected by it.   On the
fifteenth there was an abcess formed in the calf of
the leg;  he was still very much indisposed in his
general  health; on  the nineteenth  a  second ab-
 scess formed, a little below the other, and  the two
 openings communicated with one another,  the cel-
 lular membrane under the  skin  having been de-
 stroyed.

    From this time he  became daily  worse ; on the
 thirtieth day he had a cough, loss of appetite, and
 hectic fever.   As it was conceived these symptoms
 arose from the air of the hospital disagreeing with
 him, it was proposed he should be immediately re-
 moved into private lodgings, but from several cir-
 cumstances this was not done till the  fortieth day.
 He  was no sooner -out of the air  of the hospital
 than he was able to  sleep, and recovered his appe- 
      A VARICOSE STATE  OF THE LIMB.      263

tite ;  and in three weeks  time his general health
was re-established, all the ulcers formed by the dif-
ferent abscesses were healed, and he returned to his
master.
« 
264
OF ULCERS ATTENDED  WITH
                   CASE  IX.


    John Baker, a labourer, aged  sixty-two, twenty
 years ago, by  accident,  cut one of the branches  of
 the vena saphena with a bill; the  wound very soon
 healed, but the branches of the vein became enlarged
 and varicose, and have occasionally been painful
 ever since, when pressed.

    In August, 1796, he received a  hurt on his inner
 ankle, which formed an  ulcer; he went on for two
 months making use  of different applications, but  at
 the end of that time it became  so large and painful,
 that he  was  induced to  apply for  relief at St.
 George's hospital.  He  was admitted on  the 8th of
 October.  Upon  its  being explained to him  that
 the ulcer was prevented from healing by the enlarge-
 ment of the veins  of the leg, he readily submitted
 to any operation which would facilitate the cure of
 the ulcer.

   On the 10th the vena saphena was taken up ; soon
 after this operation, the pain which he had felt in the
vein, when pressed, gradually became  less, and the 
A  VARICOSE STATE OF THE LIMB.     265
ulcer had diminished in size.  The only dressing
employed was dry lint.   On the seventh day after
the operation, the ligature was removed, and  the
wound looked  very well; it continued healing  for
several days,  after which it inflamed and spread,
the ulcer on the ankle taking on the same disposi-
tion.  Under the use of the carrot  poultice this in-
flammation subsided, and the parts again put on  a
healing appearance.  At the end of five weeks the
man was  discharged, the wound made  in taking up
^the  vein being completely healed, and the ulcer on
the ankle  so very small, that he could not be induced
to remain longer in the hospital.

   In these cases the vena  saphena was taken up on
account of ulcers on the leg, proving so obstinate un-
der  every mode of treatment which could be devis-
ed, that the patients readily submitted to the  opera-
tion, with a view to have them healed.

   In all of  them, the ulcers put on a much more
healthy appearance, in less than three days after the
operation; and from that time, where no circum-
stance occurred to prevent it, went on healing like
ulcers in healthy parts.

   The veins of the limb in all of them became  evi-
 dently smaller  next  clay, in some of the cases  in a
                         z 
266       OF  ULCERS ATTENDED WITH

very remarkable degree ; and in the course of a
week they were in general very much diminished in
size.

   In those cases that were attended with fever, in-
flammation, and general loss of health, all these, ef-
fects were combined in the same case, and so very
similar to what occurs in hospitals, from change of
mode  of life, and a more confined situation than  the
patient has been accustomed to, that they are partly
 to be  attributed to these circumstances, and might
have taken place, if no operation had been perform-
 ed.   It is natural at the same time to suppose, that,
in irritable habits, applying a ligature round a large
vein may so far affect the general system, as to  dis-
pose the body to be more readily affected by such
causes.

   That it may not  appear that too much stress has
been laid upon the effects which confinement and the
air of an hospital have upon the constitution of many
individuals, particularly  after having undergone an
operation, the following remarks are stated on that
subject.

   The injury the  constitution receives from  long
confinement in an hospital is sufficiently understood;
but that it can suffer in so short a period as a week, 
      A VARICOSE  STATE OF THE LIMB.     267

or a  fortnight,  will not be so readily believed, al-
though instances of this  kind are  not unfrequently
observed in practice.  Were these effects confined
solely to hospitals, they might  be attributed alto-
gether to bad  air,  much to the discredit of those
charitable institutions ; but this  is by no means the
case, as the  same thing happens to private pa-
tients.

  In three different instances of young women, who
came out of the country to have operations  per-
formed in  London, their health began to fall off at
the end of the fortnight, and continued to decline
till they were carried out into the air ;  and from the
time of taking the first airing there was  so  evident
an amendment, as to show that air alone was suffici-
ent to bring about a recovery, which very soon took
place, by daily going out in a carriage.   Their lodg-
ings were in the neighbourhood of Leicester-square,
which cannot be considered as a very confined situa-
tion.  After getting well, their general health did
not  suffer from remaining some weeks in the same
lodgings ;  so  that  London could not be  said  to
disagree  with  them.   In conversations upon this
subject with two of these patients, they mentioned,
that they never could bear being confined to their
room, even for a few days, without suffering from it. 
■26S       OF ULCERS ATTENDED WITH

  If this ever happens in private practice, it must
very frequently occur in all hospitals, even the most
airy, both from the  construction of  the wards, and
the situation of the buildings.   Gardeners, farmers,
and persons of that description, are soonest affected
by it; and many  instances have occurred of their
losing their  health  in less  than  a fortnight in  St.
George's  hospital, and getting well in a few days
after being more in the air.

   The foregoing  cases were the only ones  which 1
had met with at the time the first edition of this work
was published, and they are now reprinted, with the
same remarks annexed to them as in that edition.

   Since that time, a great many similar cases have
 come under my observation ; from these it is evident
 that the fever and inflammation, which occasionally
 take place, are direct consequences of the operation,
 and arise from the inflammation  extending itself
along the vein, sometimes in both directions, but
 more commonly towards the foot.

   This being ascertained, it  naturally  leads me to
point out in what manner these consequences may
be obviated ; this may be readily done by including
the vein in  two ligatures, distant about half an inch
from  each  other, and cutting  the vein across in the 
        A  VARICOSE STATE OF  THE  LIMB.   269

 intermediate space; by this  means the two ends of
 the  divided vein are allowed to contract,  and the
 inflammation does not extend itself beyond the li-
 gatures.

   If such  inflammation was a constant attendant
 upon the operation of tying the vein  in the  more
 simple manner, this compound operation should un-
 doubtedly be  always  preferred ;  but as it only hap-
 pens occasionally,  and is ultimately productive  of
 benefit to the patient, by obliterating a greater extent
 of the vein, and making  him less liable  to a recur-
 rence of the disease, it becomes a question, whether
 there are not more circumstances in favour of the
 one than the other.

  There are cases, in which exposing the vein for
 half an  inch  in extent would be a very difficult and
 severe operation ;  and there  are others, in which it
 may be done with  the greatest ease ;  there are con-
 stitutions, which would lead  the surgeon to expect
 great irritability  in the  venal system ;  others, in
 which there are no grounds for such a supposition;
 it must therefore be left to the judgment  of the sur-
 geon to  decide which mode is  best  adapted to the
 individual cases under his care ; but when the trunk
of the vein at the part  where it is to be taken  up  is
                      z  2 
270
OF ULCERS  ATTENDED WITH
unusually large,  and there are dilatations forming
pouches immediately above and below that part, the
vein should be always taken up  by two ligatures,
and divided in the intermediate space.
  While this sheet was in the press, my friend Dr.
Baillie informed  me  that Ambrose Parey had not
only proposed the same operation, but performed it
in exactly the same way.  This  author I had  not
before consulted, taking it for granted that Wise-
man, who has professedly given the opinions of the
ancients, had stated every thing material from their
works.

   Upon consulting Parey, I find  the  state of the
veins just mentioned is that in which he recommends
the  operation; although the principle on which  it
 was proposed is  erroneous, he has undoubtedly the
 merit of pointing out the most simple mode of doing
 it, as well as of stating the advantages the ulcer on
 the lower  part of the leg derives from the operation.

   Had  I  been acquainted with  his observations, I
  should  certainly in the former edition have done 
        A  VARICOSE  STATE OF THE LIMB.      271

him that  justice which is  due to  him, and which I
now do, by inserting his  remarks  in the annexed
note.*

   * A varix is therefore cut or taken away, to intercept the pas-
 sage of the blood flowing to an ulcer seated beneath, or else,
 lest that by the too great quantity of blood the vessel should
 be broken, and death be occasioned by ahacmorrhagie proceed-
 ing from thence.  Now this is the manner of cutting it:  let the
 patient lie upon his back on a bench or table,  then make a li-
 gature upon the leg in two places, the distance of some four
 fingers each from other, wherein the excision may be made, for
 so the vein will swell  up and come more in sight, and besides
 you may also mark it with ink; then taking the skin up between
 your fingers, cut it longways, according as you have marked it;
 then free the bared vein from the adjacent bodies, and  put
 thereunder a blunt pointed needle (lest you prick the vein)
 thred with a long double thread, and so bind it fast;  and then
 let it be opened with a lancet in the middle under the ligature,
 just as you open a^ein, and draw as much therehence as shall
 be fit: then straight  make a ligature in the lower part of the
 fbrementioned vein, and then cut away as much of the said
 vein as is convenient  between the ligatures, and so let the ends
 withdraw themselves  into the flesh above and below ; let these
 ligatures alone until such time as they fall away of themselves.
 The operation being  performed, let an astringent medicine be
 applied to the wound and the neighbouring parts, neither must
 you stir the wound any more for the space of three days." A.
 Parey's Works, translated by Johnson, folio edition, page 319. 
CHAPTER X.
 THE EFFECTS OF LIGATURES ON VARICOSE  VEINS
    IN CASES OF ENLARGED  VENA SAPHENA, VARI-
    COCELE, AND PILES.

  A he diseases which are considered in the present
chapter do not belong to the general subject of the
workj having no connection  whatever with ulcers;
but as the treatment which is proposed was first
suggested by attending to the effects of a varicose
state of the veins upon  ulcers,  and the advantage
derived to the ulcer from the trunk of the vein being
included in a ligature ;  it must be allowed that the
following observations throw additional light on the
beneficial effects of that operation. 
THE EFFECTS OF LIGATURES,  &C.    273
ON TYING THE  VENA  SAPHENA, TO  RENDER  IT
                 LESS VARICOSE.


   From the cases stated in the  last chapter, it is
evident that the branches of the vena saphena be-
come diminished in size after the operation of tying
the trunk, but this might be pardy attributed to the
effect of  the operation upon the ulcer ; for improv-
ing the state of the ulcer would naturally remove a
considerable degree of irritation from the veins of
the leg.

   That it does not depend upon that  cause will be
sufficiently proved by the following cases.

   It is proper to remark that the only cases of this
disease, in which great benefit is to be expected,  are
those in which the enlargement belongs to the bran-
ches of the vena  saphena, major or anterior ;  for
where all the smaller branches upon the foot and leg
are universally affected, the disease is too general
to admit of relief from any one  trunk being taken
up. 
274       THE  EFFECTS  OF LIGATURES
  When the branches of the posterior vena saphena
are enlarged, it would be natural to expect the same
degree of advantage  from  taking up the trunk in
the ham, but that does not happen; this vein  has
been taken up in several instances, but  in none of
them was the benefit sufficient  to encourage a re-
petition of the operation in similar cases.- 
ON VARICOSE  VEINS.
275
                   CASE 1.


  A. B. thirty-five years of age, a house-painter
by trade, came to St. George's hospital, in the year
1794, to have advice for a weakness in his limbs,
that  rendered him unfit to follow his business,
which required  him to stand a great deal.  Upon
examining his legs, the veins were extremely large
and varicose, equally so  on both of them; there
was  no local  disease  of any kind,  only pain and
inability to stand long at a time.   He was probably
rendered more  liable  to this disease by the debili-
tating effects of lead.

  From the success met with in the cases above re-
lated, it was thought he might receive material be-
nefit from having the vena saphena taken up, it was
therefore proposed to him that it should be tried in
one leg; andif he found sufficient  advantage from it,
he could have it done on the other. To this he readily
assented, and the operation was performed.  In this
case  there was a considerable vein close to the vena
saphena, which was included in  the  same ligature ;
the operation gave  little pain, and was not followed 
276       THE EFFECTS  OF LIGATURES

by any uneasiness: the ligature came away  on the
ninth day, but the wound did not heal;  he became
faint and languid,  had tremblings and cold sweats,
with loss of appetite.  These symptoms came on
after being a fortnight in  the house, and appeared to
arise, in some measure, from the air of the  hospi-
tal disagreeing with him ; that this  was partly the
cause, was confirmed by their being much relieved
by getting him to walk  out every day in the air,
and by the internal use of Peruvian bark.  As soon
as he recovered,  which was in about a month, he
was advised to go into the country, and re-establish
his general health, for the confinement in an hospi-
tal disagreed too much with his constitution, to ad-
mit of any thing being done at that time to the other
leg ; and at some future  period he might return, if
the result of the operation encouraged him to have
it repeated.  No opportunity has occured of seeing
him since that time, so that no conclusions can be
drawn from this case, beyond the immediate effects
of the operation, which were favourable, the veins
of the limb being  rendered much smaller than they
were before. 
ON VARICOSE VEINS.          2*77
                  CASE  II.


  Thomas Gough, aged forty, came to St. George's
hospital,  and was admitted under my care, on ac-
count of  weakness and  swelling in the right leg,
which prevented him from engaging in any employ-
ment of fatigue ; there was no  ulcer upon the leg,
but a constant  degree of uneasiness,  which was
always increased by standing or walking.  On exa-
mining the leg, the veins were much enlarged and
varicose, and,  what  is unusual, there were two
venal trunks passing tip the thigh, one the vena
saphena,  the other a  branch of nearly the  same
size,  at some distance from it.  It was proposed
that both of them should be taken up: as, however,
they were too much apart  to be included in one
operation, and too near to admit of hoth being ta-
ken up at the same time, without the inflammation
extending over the intermediate  space, it was deter-
mined to  take them up separately, allowing the in-
flammation from the first operation to go off before
the  second was attempted.   On July the 22d  the
                      a a 
278       THE  EFFECTS  OF LIGATURES
vena saphena was taken up :  on the 26th the liga-
ture was  removed, and the  wound had a very fa-
vourable  appearance ;  on the 29th the collateral
branch  was taken up ; and on  August  the 2d the
ligature was removed.   The leg was less swelled,
and entirely free  from pain,  the veins appeared to
be contracted in their size, and on the 5th he went
into the country, one of the wounds being entirely
healed, and the other nearly so. 
ON VARICOSE  VEINS.           279
                  CASE  III.


   John Mathews, aged twenty-six, a gentleman's
servant, came into St. George's hospital on the 19th
of April, 1797, on account of a varicose state of the
veins of the right leg.  He perceived,  about ten
years before, that the veins of the leg were larger
than those of the other, and whenever he stood or
sat long in the  same posture, they swelled and be-
came painful.   Three years ago he received a cut
upon the inner ankle, which divided a branch of the
vena saphena; it bled profusely, and the hemorrhage
returned several  different times.  Two years after
that he bruised  the same leg against a cartwheel, and
hurt i t  so much  as to be confined  to his  bed for
seven weeks with a large ulcer, situated  upon the
inner side of the leg, a little above the ankle-joint;
this ulcer healed under the use of a  tight bandage,
applied  to the  whole limb, from the toes  to the
knee.

  The varicose state of the veins was now his only
complaint, and it was so troublesome, as to induce
him to come into the hospital, for the express  pur- 
'280     THE EFFECTS OF  LIGATURES

pose of having the trunk of the vena saphena taken
up, to relieve the branches situated  upon the leg
from the pressure of the column of blood, bv which
the dilatation was continuing to increase.

   Upon examining the limb, the dilatation seemed
to  be confined to those branches  which form  the
vena saphena ; but the trunk of this vein was deeper
seated than common;  it did not lie loose under the
skin,  but  imbedded in the  fat and cellular  mem-
brane ; this was bo  much  the  case, that  it became
necessary to make compression upon  the  thigh, to
render the vein more prominent.  After dividing
the skin, the  vein was not exposed clearly to view,
but it  was now very distinctly felt.  Under these
circumstances I applied the forefinger of the left
hand  upon the vein,  as a guide to the  knife, and
detached the  fat and cellular membrane on one side
with the point,  so as  to  make room  for the blunt
needle to get  readily behind the vein: in this way
the ligature was passed round it, and tied in the
same  manner, as has been mentioned in  the other
cases.  The  operation was  performed on the 22d
of  April;  on the 25th, which was the third day,
upon removing  the dressings  and sticking plaster,
there was an  erysipelatous inflammation, extending
a little  way up the thigh  and down the leg,  in the
course  of the veins; this induced me to  cut out 
             ON  VARICOSE VEINS.          281

the ligature, from the idea that this inflammation
was brought on by it.   He felt immediately easier;
on  the  fourth  day the  inflammation  was  much
abated, and on the fifth it was quite gone off.  He
now mentioned that the pain he had been accustom-
ed to feel  in the veins of his  leg was gone  away.
On the sixth day the wound was reduced to a small
superficial ulcer, which healed up in a few days.
A a 2 
282
THE EFFECTS OF LIGATURES
ON  TYING THE  SPERMATIC  VEIN  IN  CASES  O*
                  VARICOCELE.

  Cases of varicocele are by no  means  uncommon,
but they rarely increase to so great a size, as to
lead the patient to the idea of having any operation
performed for their relief.

  They almost always happen  in the  left testicle
and spermatic chord, in consequence of the returning
blood from that testicle having a circuitous route to
the vena cava ; the spermatic vein terminating most
commonly in the  left emulgent vein, and when it
does so, the  angle at which they  unite is nearly a
right angle

  From the following case it appears, that in some
instances this disease  becomes so distressing  as to
make the  patient seek relief at any hazard, and the
symptoms that occurred  were such as would lead
me, in any future operation of the  same kind, to
take up  the  vein  in  two  places, and divide  the
intermediate  portion,  with a view to make the in-
flammation less liable to run  along the  vein,  and
 onsequently render the pain less  severe. 
ON VARICOSE  VEINS.
283
                    CASE.


  George York, aged twenty-eight, a tailor by trade,
in the year 1788, while in North America, had a hy-
drocele, which was cured by means of a seton passed
through the sac of the  tunica vaginalis.  It was
three  months before he recovered from the effects of
the  operation ;  and three months after he got well,
the testicles seemed to enlarge, and the scrotum be-
came  very uneasy when pressed.  He came to Eng-
land in the year 1795, and  applied to several sur-
geons for relief, the scrotum being at that time so
large, and the testicles so uneasy, that he could not
follow his usual occupations.   He was  directed to
live low, and  take internal  medicines of a cooling
and purgative  nature;  to apply the solution of sal
ammoniac to the part, and to keep it  suspended.  He
followed this plan for some weeks; but, receiving-
no benefit, relinquished it.

  His complaints preventing him from pursuing the
only mode of life by which he could get a livelihood,
which was going to sea as a ship-tailor, he was very 
284       THE EFFECTS OF  LIGATURES

desirous of having something done for his recovery.
He came to St. George's hospital, and consulted me
how far any operation could be performed for his
relief, as he was willing to submit to the loss of the
testicle, rather than continue in his present state.

  Upon examining the parts, the scrotum was found
to be unusually thickened, and the veins of the left
testicle  to  be so much enlarged, as to increase its
bulk beyond what is considered as a large hydrocele.
The veins  were all convoluted,  and moved readily
on one another, and appeared to be the only cause
of this  increased size of the testicle.   On the tes-
ticle of the right side there was an incipient hydro-
cele, containing about two ounces of water.

  In this state of the left testicle little was to be ex-
pected from internal medicines, and the removal of
it appeared to be a cruel operation.  The patient
could not  be  prevailed upon longer to go on  with
his  complaint in its present state.  He  had be-
fore been told that the disease was  an enlargement
of the veins ;  and had seen two patients of mine in
the  hospital,  who had received considerable benefit
in cases of varicose veins of the leg, by having the
vena saphena taken up at the  knee, and wanted to
know if a similar operation could not be performed
upon the veins of his testicle.   The only answer 
©N VARICOSE VEINS.           285
 made to this question was, that I would not propose
 to him any such operation, having no knowledge of
 its effects ; at the same time believed there was so
 little danger in it, that if he chose to have it perform-
 ed, I had no objection to comply with his desire,
 although I did not feel myself authorised to take it
 entirely upon myself.   I  begged  he  would not at
 that time come to any resolution, but turn it in his
 mind before he came to a determination.

  He returned to the hospital  some days after, and
 said he was  resolved to have the veins  taken up;
 and  the operation was performed on the  15th of
 March,  1796, in  the following manner:  I  en-
 deavoured to find the  spermatic chord, and having
 done so, grasped it between my finger and thumb,
 and pushed forwards the surrounding veins, so as to
 make them press against the external skin of the scro-
 tum :  while the left  hand was thus engaged, I di-
 vided the skin, without wounding the veins ; and
 the  moment the incision  was made, several convo-
 lutions  were protruded between  the lips of the
 wound, covered by a strong tendinous fascia, which
 confined  them in  their situation ; when  that was
 cut  through, they projected beyond  the aperture ;
it was necessary to  divide this fascia a little  more
freely, to get readily behind this vein, which by its
convolutions on itself formed a thick plexus. A 
286      THE EFFECTS OF LIGATURES
needle, the point of which had been rounded off,
was then passed behind  the  convoluted  vein, and
inclosed it in a ligature.

  The moment the  ligature  round  the  vein  was
drawn tight, a cold sweat came on, and he fainted
away : in a few minutes he recovered, and was to-
lerably well.   For the first three days nothing par-
ticular occurred, the wound had no unusual appear-
ance.  On the fourth day his tongue became white
and dry, his  pulse  small and low, the beat not ex-
ceeding fifty  in a minute ; these symptoms coming
on unaccompanied with any  change of the local ap-
pearances,  led to the belief  that  they were not the
effects of the  operation, but the symptoms of a com-
mon fever ; and this was strongly corroborated by
the circumstance of there being two or three patients
in the hospital attacked in a  similar way, indepen-
dent of local  injury.   On the fifth  the parts were
very tender and uneasy,  and  put on a sphacelated
appearance, but the fever had abated.  Eighth day
the ligature came away, and he  was now so free
from the fever as to take the bark.  The  abatement
of fever and  irritation immediately after the coming
away of the  ligature, is  sufficient  proof that  they
were brought on and kept up by the presence of the
ligature.  Twelfth day, the  wound became  very
irritable,  and could not bear the  dressing ; the 
ON  VARICOSE VEINS.
287
parts  were  therefore fomented  every hour.   He
took thirty drops of aether  and tincture of opium,
as often as was found necessary to take off the pain,
which was very acute.   On the sixteenth the sloughs
were entirely separated from the wound, and it put
on a healthy appearance ; and on the twenty-fourth
day it became a superficial ulcer :  and by the twen-
ty-sixth was perfectly well.   At the time the wound
healed,  the testicle and  its  vessels were diminished
to one half of the size they  had acquired before the
operation.

  He was kept in the hospital, and had the opera-
tion for the radical cure performed on the hydrocele
of the tunica vaginalis  of the other testicle.  This
was done by an injection of equal  parts of wine and
water, and succeeded  perfectly.. He then left the
hospital, having continued  there a month after he
had got well of the operation for the varicose veins ;
the  parts  remained in the  same  diminished state,
not being at all affected by the operation for the hy-
drocele, although so near them.

  On the 30th of November he returned to the hos-
pital, with a view,  he said,  to have the testicle still
more reduced,  by having  another vein taken up.
From this I endeavoured to dissuade him, by point-
ing out  the violence of the former symptoms ; but 
 288      THE  EFFECTS  OF LIGATURES

 the benefit he had received from  the first operation
' had so strongly impressed him  with a belief that
 another operation would complete the cure, that all
 the arguments urged in favour of his being satisfied
 with his present state were  in  vain. *  Finding he
 would be unhappy unless something more was done,
 and there  being no apparent  clanger in taking up a
 large  vein, which lay very superficially on the an-
 terior part of the spermatic chord, no further objec-
 tion was made to his wishes, and he was taken into
 the hospital for that purpose.

   On the. 2d of December this  vein was taken up
 while the patient was in an erect  posture, exactly in
 the manner described in the cases  of the vena saphe-
 na.   As soon as the ligature was  passed behind the
 vein, the man fainted, but recovered upon being laid
 in an horizontal position.

   As the immediate symptoms in the last operation
 had been  very severe,  with  a view to mike them
 less so in the present, the vein was not immediately
 tied, but left till the next day with a  loose knot upon
 it ; he had an  opiate given  him, but had no sleep
 in the night; he was however tolerably free from
 pain.   Next day the ligature was tied as tight as the
 parts  could bear.   This  did not produce any pain
 or distressing symptoms.  On the  fifth day from. 
ON VARICOSE VEINS.
289
the operation the ligature was removed, by dividing
the noose with a pair of scissors, and the wound was
treated as a superficial ulcer.  The general bulk of
the testicle was become much smaller, and the parts
free from any degree of inflammation.   On the
thirteenth, on  account of some very  indecent con-
duct, he was discharged  from the hospital by order
of the Board, the wound  being nearly healed.

  I have since heard that he imprudently .exposed
himself in the very severe weather about Christmas,
caught a violent cold, which fell upon his bowels, and
carried him  off.
Bb 
290     THE EFFECTS OF LIGATURES
ON TYING PILES SO AS TO PREVENT THE PAINFUL
   SYMPTOMS USUALLY PRODUCED BY THAT OPE-
   RATION.

   PILES have their origin in a varicose state
of the veins of  the inferior part of the rectum and
verge of  the anus.  There  are some natural cir-
cumstances attending these vessels, which render
them more liable than any other veins in the body
to this disease : their trunks  are within the cavity
of the abdomen, and the inferior branches pass up
between the lining of the  intestine and the sphinc-
ter muscle, to bring back the  blood from the verge
of the anus.  From  these  circumstances, when
the contents of the lower bowels are in a solid form,
the veins are  compressed between them  and the
muscle during  the  time  of  their  expulsion ; and
on the other hand,  when the lower bowels are
much irritated, as in diarrhoea or dysentery, attend-
ed with tenesmus,  although the  contents are li-
quid, the action of the muscle is so violent as to
compress the veins,  and prevent the blood from
passing freely through them.

  From  these  causes piles  are first  brought on,
and afterwards  gradually increased. 
ON VARICOSE  VEINS.
291
  Piles are of two kinds, internal and external:
the internal are those formed within the anus, and
only protruded at the  time of  going  to stool; the
external, those that appear upon the verge of the
anus, and never change their situation.

  The internal ones project inwards into the ca-
vity of the gut, like berries, and, in  general, are
two or three in number, most commonly three;
they are  soft  and loose in their texture in  their
easy state,  but when  inflamed are as turgid as a
ripe grape, and when punctured,  or when  they
burst, which   sometimes  happens,  they bleed
freely.

  In cases  of long standing, they change their na-
ture and appearance ; their contents coagulate and
become  solid, their coats increase in  thickness,
and they resemble pendulous excrescent tumors in
other situations in the body.

  The internal piles are those which most gene-
rally require the attention of the surgeon;  and
when once  they have acquired a certain size, are
almost always attended by external ones as a con-
sequent disease.  There are, however, some in-
stances of external piles where  there are no inter-
nal  ones. 
292     THE EFFECTS OF  LIGATURES

  The modes of removing this disease in either
of these situations are essentially the same ; these
are either cutting off the projecting portions, in
whigh the convolutions of the veins are contained,
by a sharp instrument, or tying them by a ligature,
so tight as to produce  mortification in the part,
which afterwards drops off.

  The external piles very frequently have the
blood coagulated in their cells, so that when they
are cut off, the different coagula are seen project-
ing  some way from the  membrane  which sur-
rounds them.

   The modes of treating the disease when within
nhe reach of being cured, either by internal medi-
 cines or external application, is not immediately
 to our present purpose ;  it is, however, highly
 proper that  it should be mentioned in this place,
 that the disease does frequently admit of a consi-
 derable degree of palliation, and sometimes of a
 cure, by  the internal use of Ward's paste, which
 has more power over these veins in making them
 contract, than any other medicine in general use.

    The spices in Ward's paste seem to act directly
 upon the hemorrhoidal vessels, as the balsam ca-
 pivi does upon those of the urethra. 
              ON VARICOSE VEINS.          293

  Removing piles by  a cutting instrument is at-
tended with considerable pain, but this is of short
duration,  and  is so much  less severe than that
which takes place in removing them by a ligature,
that where it can be done with safety it is to be
preferred.   In this way external piles may always
be removed,  since the  degree of induration of
their  coverings, produced by constant exposure
to external circumstances, makes them less, liable
to bleed, and any haemorrhage that is brought on
is within the reach of such applications as are ca-
pable of stopping it: but this is by no means the
case with internal piles ; their coats are thin, they
are out of the  reach of having styptic applications
accurately and steadily applied to the bleeding ori-
fice, and in some instances within my own know-
ledge,  where  they have been removed  by the
knife, the bleeding has been so great as to endan-
ger the patient's life.

   As external piles are most commonly the con-
sequences of  internal ones, and  disappear when
these are removed, it will never be proper to pro-
pose any operation for external piles, till the inter-
nal have been first destroyed, and a sufficient time
has elapsed to ascertain that the others will not
subside.
                      Bb 2 
294     THE EFFECTS OF  LIGATURES

   When internal piles have arrived at a  consi-
derable size, we are not warranted in cutting them
off, on account of the bleeding, and have no other
mode of removing them with safety but by means
of the ligature.

   The common mode  of tying piles is, by passing
a needle armed with a  double ligature through the
basis of the pile, and tying one ligature on each
side, so tight as to make the pile  itself become
turgid, and afterwards mortify.  The pain attend-
ing the immediate application of the ligature, and
that which accompanies  the inflammation  it pro-
duces, exceeds any thing  met with in the most
severe surgical  operation.   It is  so great,  that
many surgeons decline performing the operation ;
and patients, however much they suffer from the
disease, are for the most part deterred from  hav-
ing  recourse to  so violent  a means of obtaining
relief.

   The observations which have been made in the
 preceding part of  this chapter upon tying veins
 appeared to me  to apply to piles, as well as other
 veins in a varicose state ;  and the great sufferings
 which patients experienced, whose piles had been
 tied,  seemed to arise  from the distended  state of
 the  veins,  the delicate texture of whose  coats
 could not bear  so great a degree of extension, 
              ON VARICOSE  VEINS.          295

without suffering from inflammation, by which the
sensibility was so much  increased as to produce
the most agonising  pain.

  This view of the subject led  me  to believe,
that if the distension was prevented, by taking up
the pile with a double  ligature,  and  opening the
intermediate portion of the enlarged veins, the
pain would be  less  severe, and  the operation ex-
actly similar to that  of  taking  up a vein in two
places, and  cutting through the portion between
the ligatures,  as has been already recommended,
to prevent the inflammation extending itself along
the vein.

  The principal objection which  presented itself to
this mode of-tying piles was, the possibility of the
part being withdrawn through the  noose,  by the
natural actions of  the intestine, as there was no
increased bulk beyond the ligatures; this, however
is not found to happen in practice.

  The first time this mode^of performing the ope-
ration was adopted, it was done in the following
manner: the internal piles were made  to protrude
externally, so as to be exposed to view, and a nee-
dle with a double ligature  was passed through the
centre of the basis of the pile, the  needle was imme-
diately cut off,  and  one of the ligatures was made 
296     THE EFFECTS OF LIGATURES

to embrace one half of the pile, and then tied with
a  single knot, tolerably tight, so as to make that
portion turgid j the top of the pile was then remov-
ed by the scissors, and the knot drawn as tight as
possible,  and then made secure by a second knot;
the other  portion of the  pile  was treated  in
the  same way.  Where  there are several large
piles,  they are all to be secured in a similar man-
ner, after having their cavities laid open, and their
contenj^ evacuated ;  the  pain from the operation
is by no means severe, it lasts for an hour or two,
and then  begins to subside, nor does it afterwards
return with any degree of violence ; on the ninth
day the ligatures are separated, and  the  patient
finds himself free from complaint: upon examining
the part, the whole of the piles are found  to have
been completely  removed.   The result of this
operation was so favourable, as to encourage  me
to pursue the same  mode of  treatment in other
 cases, whenever they occurred to me.

   In  four different  instances, two  of them  in
 private practice, and two in St. George's hospital,
 the patients have  been  operated on in this way,
 and in all of them  the symptoms have been unu-
 sually mild, and the cure completely effected.

   There is no  better mode of giving an idea of
 the difference  in violence of the symptoms in the 
ON VARICOSE VEINS.          297
common  mode  of tying piles, and that which is
here recommended,  than by stating, that  in the
usual mode the  patient suffers, in consequence of*
the operation, all the same symptoms as those of
a violent  attack  of the piles, and these are kept up
for five,  six, or seven days,  and in a very ag-
gravated  degree ; in  the present mode, the symp-
toms scarcely   exceed those brought  on  by a
moderate attack of piles, and do not continue with
that degree of severity for more than a few hours,
and then  gradually subside.

   These  four instances appear to me sufficient to
show, that in this mode the piles can be completely
removed, and  that the symptoms are  unusually
mild.  From what has been already stated upon
the subject of tying veins in general, there could
be no doubt of the advantages that would  attend
taking off the tension from the coats of the vein,
and the  only thing necessary to be known is,
whether  this can be  done, and at the same time
the pile be so secured as to answer the purpose
of removing the  disease ; the present facts  ap-
pear to establish this point, which is all that is ne-
cessary to recommend the present mode of  per-
forming  the operation. 
 
M«LHut
  VIZ  -t

H765-P \
 KM
N*
£,|
 

".> «*3
	'.ft
	4»V
• r^"^'
1 #, .••^-^-'•■^