Both this irritable and the simple ulcer are very liable to become stationary in the process of heal ing, and ultimately to be so indolent as to have no disposition to advance ; it is then termed an 'in dolent or callous ulcer,' which is characterized by the edges being thick, smooth, callous, and of a blue white colour, and by the surface of the sore being below the level of the callous margin, and presenting a smooth, glistening, flabby appearance, there being few or no granulations, and those which do exist, generally pale and languid. The dis charge is frequently thin, profuse and viscid, ad hering to the ulcer ; but sometimes it is scanty, and then the surface of the ulcer is of a brown colour. The skin around is purple and hardened, but not inflamed, particularly if the ulcer has been of any standing ; the cautancous veins are com monly varicose. The bluish white colour of the edges is the most characteristic sign of this spe cies of ulcer. This ulcer occurs, like many others, most frequently on the leg, and generally in ad vanced life ; from the age of maturity, however, all are subject to this disease, which is most preva lent in the labouring classes, and among soldiers and sailors. Its treatment consists in gently and gradually stimulating the parts to action, by the application of a solution of the sulphate of copper, and of a mild ointment of the red oxide of mercury, together with a firm compress and bandage. The judicious arrangement of compresses adopted by Mr. Whately, is particularly applicable to this ulcer. When this solution, and the ointment of the red oxide, lose their stimulating qualities, an event which occurs in all local applications, they must be strengthened gradually and cautiously ; and when the ointment has been increased to the strength of 3ij to Zi of lard ; the unguentum resinosum should be substituted for the lard. The patient should be allowed nourishing diet, and even stimulating food, and should keep the leg quiet, in the horizontal at titude. Mercury and cantharides are most power ful auxiliaries, if administered only to excite the system to greater activity. Such a numerous cata logue of remedies are recommended for this ulcer, that John Bell has humorously classified them into innocent drugs, Numerous drugs, and devilish drugs. The most common in use are adhesive plaster, ointment of the nitrate of mercury, hot dressings, which consist of resinous ointment and oil of turpentine rendered hot, ardent spirits, solu tions of nitrate of silver, nitrate of copper, muriate of mercury, oxide of arsenic, tincture of myrrh, lemon juice, and the gastric juice of ruminating animals. Of these the adhesive plaster is the most valuable, and should be cut into slips of from one to two inches in breadth, and of such a length as to extend some inches on each side of the ulcer, but never so long as to encircle the leg, since it then interrupts the circulation of the skin, unless the roller is applied tight enough to support the cuta neous circulation distad to the adhesive strapping. The slips or straps are applied across the sore, pre viously beating them gently by drawing the back of the plaster along the surface of a smoothing iron. The lowest or distad one should be first put on, by fixing its one extremity to the sound skin on the one side of the ulcer, where it ought to be retained by the hand of the patient, and pulling it across, while with the fingers of the left hand, the oppo site sides of the sore ought to be approximated as much as possible, before applying the other ex tremity of the strap to the sound skin, because the intention is to bind or approximate the edges by force. As many straps should be used as to extend fully one inch at each extreme of the ulcer, and not overlap each other, but rather to have a small gap between each, to allow the matter to exude. Over the adhesive straps, a compress of tow, and lastly, a bandage are used. The ointment of the red oxide of mercury is preferable to the nitrate. Warm dressings are a powerful remedy, but difficult to manage. Ardent spirits and tincture of myrrh are beneficial. The nitrates of silver, copper, the mu riate of mercury, and oxide of arsenic are escharo tics, and not stimulants like the sulphate of copper, therefore inadmissible in this species of ulcer. The sulphate of copper never acts as an escharotic, even in its crude state, but always as a stimulant ; and it is only when strong compression is combined with its application, that it appears to act as an escharotic, but in reality only as a powerful absorbent. The
lemon juice is a good application, and so also is the gastric juice of ruminating animals. The bluish white callous border ought never to be excised with a knife, or destroyed with caustic, as it is the newly formed skin sparingly supplied with blood vessels. This callous margin indicates want of action, and is the most favourable for the applica tion of the adhesive strap.
This indolent ulcer, the most generally met with in practice, is frequently healing in one part, while inflamed and phagedenic in another, apparently from the extent of surface involved ; as it sometimes ex tends from the knee to the ankle joint ; and in this case, the inflammatory and phagedenic disposition must be thoroughly subdued by fomentations, poultices, rest, and low diet, before any attempt to heal the callous portion ; and even when this irritable disposition has been removed, caution must be observed before we have recourse to exciting treatment, so that simple dressings may be advantageously applied for two or three days. The same inflamed and pha gedenic action is also liable to attack this ulcer while under treatment, when the same means must be adopted. The securing of the saphena major vein with a ligature, as practised by Pare, Wise man, and Sir E. Home, is now abandoned in conse quence of the inflammation which is sometimes in duced ; but this vein, in all cases where it is vari cose, should be obliterated with the potassa above the seat of the ulcer.
The fungous ulcer is merely the simple ulcer which has arrived at the level of the skin, and in stead of cicatrizing, shoots forth luxuriant granula tions, which become pale and flabby, and in com mon language termed proud flesh, when the sore is of small magnitude. Neither the irritable nor the callous ulcer can produce these exuberant growths, for in the former there is too much action, which checks their production, and in the latter the ac tion is defective. These granulations are found in ulcers occurring in the venereal and scrofulous con stitutions, as well as in the cancerous and carious ulcers ; and in the latter these fungous excrescen ces are best exemplified. The treatment consists in reducing the exuberant granulations by the ni trates of silver or copper, to the level of the skin, when they generally cicatnize.
By the Phagedenic ulcer, is generally considered Gangrena Phagedena, or hospital gangrene, but there is a phagedenic ulcer destitute of a sloughing or mortifying disposition, although it eats away to a horrible extent, being derived from (pay., to eat: it is termed by Sir A. Cooper, the gangrenous or sloughing ulcer. It occurs commonly after an ulcer has been neglected or suffered to remain too long open, and not unfrequently in the syphilitic constitution. It is characterized by irregular knotted edges, which are smooth and flat on one side, and on the other high and rugged; by its healing in some points, and spreading rapidly in others, but still advancing in extent as a whole; the surface also sometimes looks well, and at others ill conditioned; the discharge is occasionally purulent, at other times thin and ichorous, and sometimes so profuse as to induce hectic fever; the skin around is purple and violaceous, and more so where it is phagedenic; the pain is very acute, and at times quite insufferable; the inflammatory action is more frequently chronic than acute, becoming acute only occasionally, from some source of irritation. This ulcer attacks the integuments of the legs, the labia of the female; the penis, the scrotum and nates of the male. The treatment consists in subduing all irritation and inflammation by anodyne fomentations and poultices, low diet and absolute rest; then the application of weak escharotic solutions, together with a weak ointment of the red oxide of mercury; these should be changed or increased in strength, whenever they appear to lose their effect. Not unfrequently they produce too much irritation, and require to be given up, and to have substituted the fomentations and poultices. The chief object to be observed in this ulceration, is to endeavour to arrest its progress, and to change it from this inveterate species to the simple ulcer. Nothing is so beneficial in the treatment of this and all inveterate ulcers as change of air. The diet should be mild, con sisting of vegetables and fruits, together with poul try, eggs and milk, and the decoction of sarsaparilla with the compound calomel pill may be given. This ulcer may be termed the simple phagedenic ulcer.