THE 
PATHOLOGY AND TREATMENT 
OF 
CHRONIC ULCERS. 
BY 
B. A. WATSON, M. I)., 
SURGEON TO JERSEY CITY CHARITY AND ST. FRANCIS’S HOSPITAL*. 
LREPRINTED FROM THE NEW YORK MEDICAL JOURNAL, JULY. 1875.J 
i\EW YORK: 
D. APPLETON AND COMPANY, 
5 4 9 & 5 5 1 BROADWAY. 
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D. APPLETON Sf CO., Publishers, 
549 & 551 Broadway, New York. THE 
PATHOLOGY AND TREATMENT 
OK 
CHRONIC ULCERS. 
BY 
B. A. M. D., 
SURGEON TO JERSEY CITY CHARITY AND ST. FRANCIS'S HOSPITALS. 
IUKPRINTED FROM THE NEW YORK MEDICAL JOURNAL, JULY, 1875.J 
YORK: 
I). APPLETON AND COMPANY, 
5 49 & 55 1 BROADWAY. 
1875. THE PATHOLOGY AND TREATMENT OF 
CHRONIC ULCERS. 
The study of the pathology of chronic ulcers necessarily 
involves a brief consideration of the origin and characteristics 
of that class usually designated as acute, since the former dif- 
fer from the latter in so slight a degree as to render it fre- 
quently difficult to determine satisfactorily where the one ends 
and the other begins. Acute ulcers frequently become chronic, 
and chronic occasionally acute. Whether an ulcer becomes 
chronic or not, frequently depends upon its size, location, the 
condition of the patient’s general health, and the presence or 
absence of local irritation. We often see large chronic ulcers 
situated on the upper extremities and various parts of the 
body, which have resulted from deep and extensive burns; 
but the smaller ulcers thus favorably situated usually heal 
without reaching the chronic stage, unless the patient’s health 
has been previously vitiated. Local irritation, unaided by 
other influences, seldom produces the characteristic chronic 
ulcer on other parts of the body than the leg, and when thus 
situated the proper management requires much skill and con- 
siderable patience. 
“ Few practitioners look upon this class of diseases in the 
true light of philosophy; their ideas of their pathology are 
vague and indistinct; and it is not, therefore, surprising that 
they should find themselves completely baffled in their efforts 
at curing them. It is for this reason that chronic ulcers of 
the legs have so long been regarded as an opprobrium of sur- 
gery, and that so many patients are obliged to carry their 
malady with them to the grave, notwithstanding the numer- 
ous attempts that may have been made to get rid of it; all 4 
arising from the fact that its true nature was never properly 
understood.” 1 
That we may better comprehend the nature of chronic ul- 
cers, and thereby be more successful in their treatment, it will 
be necessary for us to begin the investigation with the patho- 
logical changes in the parts immediately preceding their for- 
mation. 
u The first change that we see in irritated living tissue is 
dilatation of the vessels; the immediate result of this is re- 
tardation of the flow of blood, increased transudation and a 
collection of white blood-cells in the periphery of the cali- 
bre of the vessels, the w’all of the vessels gradually grows 
softer, possibly from the long contact with the white blood- 
cells, which gradually enter and finally pass through the 
walls.” 2 
Following this condition and dependent on it are the infil- 
tration of the tissues aud defective nutrition of the parts. 
These changes may be the result of local injury or constitu- 
tional disease. The local injury may be mechanical or chemi- 
cal. The constitutional disease may be specific or general. 
The infiltration is caused by the escape of “ wandering white 
blood-cells through the walls of the vessels, their collection in 
the tissue, with the secondary action they induce : plastic in- 
filtration, and inflammatory new formation.” 8 
The defective nutrition of the parts in cases of local injury 
may be primarily due to the destruction of the capillary ves- 
sels, or, as in cases of constitutional diseases, may depend upon 
the infiltration and resulting hypersemic condition of vessels. 
When the local injury has been sufficiently severe, a larger or 
smaller portion of integument will be ultimately thrown off 
as a slough, with more or less of the adjacent tissues, leaving 
a granulating wound or ulcer, but in other cases, where the in- 
jury has been less severe, there will be only an abrasion or 
excoriation of the skin, possibly infiltration into the cellular 
tissue, which may be followed by the formation of an abscess, 
and finally result in the destruction of the integument. In 
the former case the ulcer commences on the surface, and in 
1 Gross’s “System of Surgery,” vol. i., p. 184. 
2 Billroth’s “ Surgical Pathology,” p. 60. 3 Ibid., p. 68. 5 
the latter the abscess ends in the transformation process. In 
cases of constitutional disease, not unfrequently the first inti- 
mation that an ulcer is in the process of formation is gained 
in the discovery of a vesicle or pustule, which only needs to be 
opened to convert it into a miniature ulcer, which then often 
increases rapidly in size. It is a wrell-established fact that the 
wandering wdiite blood-cells in the tissue are followed by plas- 
tic infiltration and inflammation, and the tissue in which these 
cells are infiltrated dies, as always happens in circumscribed 
cell-proliferation. The tissue surrounding the spot first dis- 
eased is gradually infiltrated with cells; and it also goes on to 
form fluid cellular tissue wTith the character of pus; the in- 
filtrated tissue is the more disposed to suppurate and break 
down when its vessels are little developed and do not sup- 
ply sufficient qualitative or quantitative nutriment mate- 
rial to maintain the further development of the excession- 
cells.” 1 
The origin and action of pus in this connection is worthy 
of our brief consideration. Pus was formerly supposed to 
possess solvent properties ; but it is now known that “pus is 
not the dissolving, but the dissolved, i. e., the transformed 
tissue. A part becomes soft, and liquefies wdiile suppurating, 
but it is not the pus which occasions this softening; on the 
contrary, it is the pus which is produced as the result of the 
proliferation of the tissue.” 2 
Paget believes that inflammatory lymph is readily con- 
verted into pus, and'in fact that this is its usual origin. Bill- 
roth says : “ Pus is fluid, as it melted, dissolved inflam- 
matory new formation. When pus is present in quantity, it 
must have come from some sort of granulation tissue, or from 
some other highly-vascular and usually liighly-cellular source ; 
this source need not always be a surface, as in the present 
case, but may lie deep in the tissue and form a cavity; the 
centre of an inflammatory new formation anywhere in the 
tissue may break down into pus.” 3 
Wandering cells as w’e see have already played a very irn- 
1 Billroth’s “ Surgical Pathology,” p. 368. 
2 Virchow’s “ Cellular Pathology,” p. 490. 
’ Billroth’s “Surgical Pathology,” p. 69. 6 
portantpart in the inflammatory action and pus-formation ; but 
this seems to be only a secondary and minor part of their work. 
The formation of granulation tissue, or the healing of wounds 
by the granulation process, is only an example of the prolif- 
eration and transformation of the wandering cells. “ That is, 
the white blood-cells become fixed connective-tissue cells.”1 
The formation of granulations on the surface of a wound is 
preceded by an exudation of lymph; or a fibrinous substance 
which, if the wound be left open, will be found to cover its 
entire surface, glazing it over with a whitish film ; “ and this, 
if it be examined with the microscope, will be found to con- 
tain an abundance of corpuscles having the appearance of 
white corpuscles of the blood.”3 
Billroth says: “The exuded fibrinous material on the 
surface of the wound becomes soft and gelatinous; at the 
same time, the infiltrated tissue of the surface of the wound 
assumes the same peculiarities; the soft connective tissue, 
into which the young vessels shortly grow, even if only pres- 
ent in small quantities, holds together the cells of inflamma- 
tory new formation, which constantly increase in numbers. 
The granulation tissue is thus formed.”3 
In the large majority of ulcers of recent formation, the first 
granulations which form are healthy, and possess the power 
of reproduction in a high degree ; but this power is gradually 
diminished until the granulations are no longer capable of re- 
producing their kind. The surgeon may be still able to urge 
forward after some delay the granulation process, but in this 
class of cases the improvement is often only temporary, and, 
sooner or later, the newly-formed cells begin to melt away, 
when their destruction is much more rapid than had been 
their growth. The loss of this power is due primarily to de- 
fective nutrition in the parts, and the inclination is to secure 
a freer development of vessels and thereby stronger cells, 
“ which do not lead to suppuration, but to connective-tissue 
new formation.”4 
1 Billroth’s “ Surgical Pathology,” p. 61. 
2 Paget’s “ Surgical Pathology,” p. 15. 
3 Billroth’s “ Surgical Pathology,” p. 68. 
4 Ibid., p. 395. 7 
The transformation of the acute ulcer into the chronic may 
he rapid or slow. Some ulcers are essentially chronic from 
their commencement, especially in cases of constitutional dis- 
ease. Chronic ulcers also differ widely in their character- 
istics, and have received a great variety of appellations, ac- 
cording to their peculiarities. I shall attempt to enumerate 
them only so far as their varied pathological character would 
seem to serve as an indication to their proper management. 
Cancerous and lupoid ulcers, although sufficiently chronic, are 
not included here—belonging more properly to another classi- 
fication—and for the additional reason that the treatment in 
these diseases differs in a marked degree from that of the or- 
dinary chronic ulcer. 
It may be advantageous in the study of this subject to re- 
call to mind the fact that chronic ulcers may originate either 
in constitutional disease, local irritation, or both ; and the same 
influences that have caused their origin may perpetuate their 
existence. The nomenclature of ulcers, it must be confessed, 
is still vague and unsatisfactory, although to some extent 
based on local conditions and constitutional diseases. The 
following names, more frequently applied to chronic ulcers 
than acute, as callous, varicose, irritable, inflammatory phage- 
denic, and exuberant, are founded on certain peculiarities or 
morbid conditions of the ulcer, or the parts more or less im- 
mediately surrounding it; while others, also essentially chronic, 
but originating in constitutional disease, are designated as 
syphilitic, strumous, eczematous, and scorbutic. These names, 
although apparently sufficiently explicit, are nevertheless fre- 
quently unsatisfactory to the surgeon, for the reason that few 
ulcers are seen in practice which do not possess a mixed char- 
acter. The varicose, like the callous ulcer, frequently has a 
hardened border and base, The induration is occasionally so 
great as to render these parts as firm as cartilage, and this 
hardness seriously interferes with the necessary flow of blood 
to the ulcer, which now becomes torpid in character. The 
inflammatory ulcer may possess the characteristics of the irri- 
table, and under these circumstances resemble both. The 
tertiary syphilitic ulcer is often found on the leg, complicated 
with the varicose condition. The phagedenic ulcer under 8 
proper management may soon lose its peculiarities on which 
the name is based; and the same remark applies with equal 
force to a large portion of the names now in common use. 
The names are expressive of certain conditions, often transient 
in character, rather than of any specific class of lesions ; and a 
consideration of these facts suggests the propriety of adhering 
as closely as possible to the primary division of ulcers into 
idiopathic and symptomatic, or acute and chronic. “Idio- 
pathic nleers are such as result from purely local irritation ; 
they may also be termed irritative ulcers. Symptomatic 
ulcers are such as from some dyscrasia appear as a symptom 
of constitutional disease, without the action of a local irrita- 
tion on the affected part.” 1 An acute ulcer is one in which 
the recuperative action preponderates over the process of disin- 
tegration. A chronic ulcer is one in which the process of dis- 
integration is equal to, or greater than, the recuperative action. 
The terms acute and chronic are used here to express a con- 
dition, without reference to the time which has elapsed since 
the formation of the ulcer, but with a bearing on the probable 
duration. It therefore follows as a natural sequence that so 
long as an ulcer remains acute the treatment is comparatively 
of little importance; but the chronic ulcer requires for its suc- 
cessful management a thorough knowledge of its pathology ; 
the power and adaptability of the remedial agents which are 
to be employed; and, finally, much skill in the application of 
the same. I have not attempted to describe the varied ap- 
pearances of the chronic ulcer, which would require much 
time and space—a repetition of an almost endless catalogue 
of names—a detail of the form, shape, color, size, location, 
character of the discharges, and the surrounding conditions, 
but have given considerable attention to its origin—have 
also alluded to some of its subdivisions, and finally offered a 
definition. It is not my intention now to enter into the de- 
tails of treatment, but I shall first attempt to inquire into the 
indications, then offer a few suggestions on their general man- 
agement, and finally conclude with a description of that 
method which will enable us, I believe, to accomplish the 
object sought, in the least possible time, in the greatest num- 
1 Billroth’s “Surgical Pathology,” p. 395. 9 
ber of cases. Ulcers originating in constitutional diseases 
furnish us a reliable indication for the constitutional treat- 
ment, and, should this indication be disregarded, failure in- 
stead of success may be confidently anticipated. It is also 
true that the constitutional treatment, although absolutely 
necessary in these cases, will result disastrously if unaided by 
local applications and the successful management of all exist- 
ing complications. Thus the tertiary syphilitic ulcer will 
require that the patient should receive constitutional treat- 
ment. 
Iodide of potassium, either alone or in combination with 
tonics, will be found not only advantageous, but often indis- 
pensable. The existing condition of the ulcer must be your 
guide for the local treatment. Should its base and border be 
found firmly indurated, or the ulcer complicated with a vari- 
cose condition of the veins of the parts, then such means should 
be employed as will remove the complication. In the em- 
ployment of further means, it should not be forgotten that, 
“to induce healing of an ulcer, the first requirement is arrest 
of the disintegration on the surface ; next, that the floor of the 
ulcer assumes, at least approximately, the character of a healthy 
granulating surface, which goes on to cicatrize in the usual 
way. In torpid, atonic ulcers it is absolutely necessary that 
there should be a free development of vessels, and stronger 
cells, which do not lead to suppuration, but to connective- 
tissue new formation; in proliferating ulcers, on the other 
hand, the new formation must be brought back to the normal 
size. As you will readily perceive, on reflection, this gives 
the indication for the local treatment to be followed in either 
case.” 1 Let us now remember, in the use of remedies, the 
indications and requirements. Our first object is, to arrest 
the disintegration on the surface of the ulcer. This process 
of disintegration, in both the constitutional and local ulcers, is 
perpetuated by irritation, and to relieve this condition is the 
great object of treatment. How can this object be most 
readily accomplished ? The patient in all severe cases must 
be kept in bed—this is the sine qua non of treatment; and 
next to this is perfect cleanliness—not merely of the ulcer, but 
1 Billroth’s “ Surgical Pathology,” p. 395. 10 
the whole person. Thus far nearly all chronic ulcers will be 
benefited by the same treatment, and a careful inspection 
will now furnish further indications for its proper manage- 
ment. Should the edges of the ulcer be indurated, inverted, 
or ragged—there being at the same time complete absence of 
healthy granulations—and a secretion of thin ichorous pus, 
then you should choose between the use of the knife, actual 
cautery, the application of caustic potash or strong nitric acid ; 
but, in more favorable conditions, a wTet compress or an emol- 
lient poultice may be sufficient to meet the indications. It 
should not, however, be forgotten that rest in bed and entire 
neatness will in the course of a few days, in nearly all cases 
of ill-conditioned ulcers, effect an almost marvelous change 
for the better. The explanation of this is to be found in the 
fact that the position will usually put an end to nearly all 
local irritation, and also greatly reduce the inflammation. 
This, however, will not be the case when the ulcer is origi- 
nated or perpetuated by dead or diseased bone, and here the 
sooner the irritation is removed the better it will be for the 
patient. With these brief allusions to the management of 
constitutional and local complications, I shall now enter on 
the consideration of the best means for the production of 
healthy granulations, and subsequent cicatrization of chronic 
ulcers. The importance of this subject demands an inquiry 
into the pathological conditions attending these processes; 
and without this knowledge it would be impossible to under- 
stand the indications for treatment. “ Hunter says: 11 have 
often been able to trace the growth and vascularity of this 
new substance. I have seen upon a sore a white substance, 
exactly similar, in every visible respect, to coagulating lymph. 
I have not attempted to wipe it off, and the next day of dress- 
ing I have found this very substance vascular; for by wiping 
or touching it with a probe it has bled freely. I have ob- 
served the same appearance on the surface of a bone that was 
laid bare. I once scraped off some of the external surface of 
a bone of the foot, to see if the surface would granulate. I 
remarked the following day that the surface of the bone was 
covered with a whitish substance, having a tinge of blue; 
when I passed my probe into it, I did not feel the bone bare, 11 
but only its resistance. I conceived this substance to be 
coagulating lymph thrown out from inflammation, and that 
it would be forced off when suppuration came on; but on 
the succeeding day I found it vascular, and appearing like 
healthy granulations.’ ” 1 This observation of Mr. Hunter’s 
wanted only the application of the microscope to show all 
that is now known in regard to the formation of granula- 
tions. 
Billroth, speaking of this question in connection with the 
treating of incised wounds, says: “ What will now take place 
in the tissue itself? Essentially, the same changes as in the 
united edges of a wound; wandering of white blood-cells 
through the walls of the vessels, their collection in the tissue 
with the secondary action they induce; plastic infiltration, 
and inflammatory new formation. But since there is no op- 
posing wounded surface with which the new tissue can co- 
alesce, then to be quickly transformed to connective tissue, the 
cells, escaping from the vessels, remain at first on the surface 
of the wound ; the exuded fibrinous material on the surface 
of the wound becomes soft and gelatinous; at the same time, 
the infiltrated tissue of the surface of the wound assumes the 
same peculiarities; the soft connective ‘tissue, into which the 
young vessels shortly grow, even if present in only small 
quantities, holds together the cells of the inflammatory new 
formation, which constantly increase in number. The granu- 
lation tissue is thus formed ; this is, therefore, a highly-vaseu- 
lar inflammatory new formation. At first it grows constantly, 
the direction of its growth being from the bottom of the wound 
toward the surface; the tissue is, however, of different con- 
sistence in the various layers, its superficial surface espeeially 
is soft, and most superficially of fluid consistence, for here the 
intercellular substance becomes not only gelatinous, but fluid ; 
this uppermost thin fluid layer, which is constantly flowing 
and being constantly renewed from the granulation tissue by 
cell-exudation, is pus”2 Having presented the subject of 
granulation, it now becomes necessary to give some attention 
to the process of cicatrization. We have already observed 
1 Paget’s “ Surgical Pathology,” p. 155. 
2 Billroth’s “ Surgical Pathology,” p. 68. 12 
that granulation begins in the bottom of the ulcer, that layer 
upon layer is formed until the ulcer has been filled on its 
periphery to the level of the surrounding skin, at which point 
the cicatrization must commence. “ The following metamor- 
phoses now gradually occur: the entire surface contracts more 
and more, becomes smaller; on the border, between skin and 
granulations, the secretion of pus diminishes; first, a dry, red 
border, about half a line broad, forms and advances toward 
the centre of the wound, and, as it progresses and traverses 
the granular surface, it is followed closely by a bluish-white 
border, which passes into normal epidermis. These two seams 
result from the development of epidermis, which advances 
from the periphery toward the centre; ”. . . . until “ finally 
it covers the entire granulating surface.” 1 It has, however, 
been claimed that, in a few rare instances, there are excep- 
tions to this rule, that all cicatrization advances from the pe- 
riphery toward the centre;2 but Billroth disbelieves this state- 
ment, and says: “ This is only true of cases where portions of 
cutis with rete Malpighii have remained in the midst of the 
wound, as may readily happen in gangrenous wounds, as the 
caustic agent may penetrate unequally deep. . . . But, if 
there be no such remnant of rete Malpighii, we never have 
these islands in the cicatrix; the formation of epidermis only 
takes place gradually, from the periphery of the wound 
toward the centre. I believe this so firmly, that I think sur- 
geons, who say they have seen otherwise, must be mistaken in 
some way.” 3 My observation confirms the opinion here stated, 
and I shall reluctantly believe that cicatrization furnishes an 
exception to the general law as given by Prof. J. J. Chis- 
holm : “A living substance possessing formative power can 
only produce its kind; and, under this general law of Nature, 
old skin alone can form new: therefore is it that islets of new 
skin are never seen dotting the surface of an ulcer which has 
extended through the entire depth of integumentary tissues.”4 
I have entered thus fully on the subject of the pathology of 
1 Billroth’s “ Surgical Pathology,” p. 66. 
2 See Paget’s “ Surgical Pathology,” p. 215. 
3 Billroth’s “Surgical Pathology,” p. 67. 
4 Richmond and Louisville Medical Journal, for October, 1870. 13 
granulation and cicatrization for the purpose of aiding the ra- 
tional treatment of these lesions. The well-merited high stand- 
ing of the authorities cited entitles their opinions to great 
weight; and the important question is now, “How can the in- 
dications be best met, and the object sought accomplished in 
the least possible time in the greatest number of cases?” I 
believe that the plan introduced by M. Hevardin not only 
enables us to heal ulcers, which otherwise would remain open 
and suppurating during the whole life of the patient, but at 
this time is the most potent power known to surgeons for heal- 
ing all chronic ulcers. It is at the same time a question to 
be determined, in each and every case of this lesion, whether 
the advantages to be gained by this method will compensate 
the patient for the additional inconvenience. Many cases of 
small chronic ulcers, although situated on the lower extremi- 
ties, have, when attended by favorable conditions, been in- 
duced to heal, while the patient continued to perform his duty 
as laborer or mechanic. In cases where the patient’s condi- 
tion forces him to attend regularly to his business, strapping- 
over the ulcer, bandaging the limb, and occasionally other 
remedies, will be preferred to skin-grafting. The preference 
is here given to other methods, although the healing is not so 
readily or perfectly accomplished. I am now satisfied, after hav- 
ing practised skin-grafting in hospitals more than four years, 
during which period I have had the opportunity of witness- 
ing the application of this method to the healing of a large 
number of chronic ulcers, and comparing it with the other 
methods now in use for the accomplishment of the same ob- 
ject, that the following are some of the advantages which 
may be safely claimed for it: It enables us to heal chronic 
ulcers which otherwise would go with the patient to his 
grave; to heal others which have resulted from extensive 
burns and complete destruction of the integument over a 
large surface of the body, with a rapidity formerly unknown ; 
and also that it produces a more healthy cicatrix, and prevents, 
to a very great extent, the deformities which otherwise would 
exist. The fact that the application of a few skin-grafts to an 
ulcer usually produces an improved condition—a vitalizing 
effect—I think will be readily admitted by those who have 14 
watched the operation; but the larger the number applied, 
the better the results obtained. The ulcer is, I believe, tem- 
porarily improved, even though the grafts fail to become ad- 
herent, but the most marked improvement is seen in cases 
where a large number of points of cicatrization have formed. 
“ Dr. Masters states, on the authority of Mr. Rivers, that an 
unhealthy or feeble stock has been restored to health by the 
imposition of a healthy graft. This fact has its parallel in 
what takes place after the surgical operation of grafting a bit 
of healthy skin upon an ulcerated surface.”1 
In regard to the effect of the healthy graft on the unhealthy 
stock of plants, I am unable to speak from my own observa- 
tion ; but, in cases of skin-grafting in ulcers, I know that the 
unhealthy ulcer is frequently transformed into the healthy 
with surprising rapidity. I now recall to mind a case in 
which nearly all the other methods known in surgery had 
been applied unsuccessfully for the healing of a very large 
ulcer, which extended from the axilla to the crest of the 
ilium, on which I applied two hundred skin-grafts, and had 
the satisfaction of seeing the patient discharged, cured, from 
the hospital within six weeks. The patient had been in the 
hospital, at the time of the application, many months, with 
no permanent improvement. Among other means attempted 
for his relief was the performance of a plastic operation, 
whereby a large portion of the ulcer was sought to be covered 
by healthy integument, cut from the adjacent parts. This 
operation completely failed, and resulted in an increase of 
the size of the ulcer. Skin-grafting not only rapidly healed 
it, but produced a firm cicatrix without deformity, and in 
which there was very little tension. The rapidity of the 
reparative process is apparently due in the first instance to 
the vitalizing effects of the grafts upon the granulations, 
whereby they are enabled to reproduce themselves with a 
rapidity very rarely seen, except as a sequel of this method; 
and, secondly, to the formation of a large number of new 
points of cicatrization, which rapidly increase in size, while 
cicatrization at the periphery of the ulcer is also very much 
hastened. I am now satisfied, after an extensive and pro- 
1 Ross, “Graft Theory of Disease ” p. 41. 15 
longed trial of tlie different methods of skin-grafting, that the 
use of small portions of healthy integument is far preferable 
to the epidermic scales or lymph. The results are much 
more uniform and certain. I prefer small portions of integu- 
ment to large ones, and believe that our greater success with 
the former is due largely to the fact that these are more 
readily kept in actual contact with the surface of the ulcer, 
than the latter. The larger portions of integument are liable 
to be raised from the surface of the ulcer by the formation of 
pus beneath th§m. I do not claim to understand perfectly 
all of the conditions essential to successful skin-grafting; but 
I am fully satisfied, and my experience justifies the conclusion, 
that perfect cleanliness of the ulcer is more important than 
any thing else. Every particle of dead tissue must be removed. 
Should the smallest particle intervene between the graft and 
the surface of the ulcer, failure instead of success may be 
confidently anticipated. This one condition being con- 
stantly kept in mind, and fully attained, the surgeon may 
then apply grafts to chronic ulcers, whether of constitutional 
or local origin, with the assurance that at least per 
cent, of all those applied will become adherent, and form new 
points of cicatrization. I am accustomed to secure the re- 
quired cleanliness by the use of the caustics, emollient poul- 
tices, and wet compresses. It often requires eight or ten days 
to prepare the ulcer for the reception of the grafts; and dur- 
ing the preparation I prefer to have my patient kept in bed, 
for reasons previously mentioned. Although a very careful 
preparation is absolutely essential to success, nevertheless 
the proper application of the grafts is of equal importance. 
In speaking of this operation, for the sake of brevity, I shall 
omit many of the important steps which have been previously 
detailed in the various articles already published on this sub- 
ject, and content myself with mentioning certain details and 
peculiarities of treatment which I have found to be advan- 
tageous. I am in the habit of applying the grafts in rows. 
The object sought in this method of application is, the reten- 
tion of the grafts in their place with the use of as little plaster 
as possible. I conceive this point to be very essential. When 
a large amount of plaster is used the ulcer is to a great extent 16 
covered with it, and beneath this plaster accumulate the dis- 
charges; the plaster is very frequently raised from the grafts, 
and the grafts may be moved from the point on which they 
were originally applied. I am satisfied that this has fre- 
quently happened in cases where the grafts were applied 
irregularly on the surface of the ulcer. The regular applica- 
tion in a continued line obviates all this danger by diminish- 
ing the amount of plaster necessary to keep the grafts in their 
places. The direction of the line will depend necessarily on 
the shape of the ulcer, since the plaster is used to protect the 
grafts, and retain them where they were originally applied. 
I therefore desire the lines to traverse the ulcer in such a way 
as to make them as short as possible. Having placed one 
row of grafts on the surface of the ulcer at regular intervals 
of half an inch I now proceed to cover this with a strip of 
isinglass-plaster, somewhat wider than the grafts. The other 
grafts are now put on in the same manner, until the ulcer 
has been sufficiently grafted, after which I place a wet com- 
press of slieet-lint over it, and then apply with moderate firm- 
ness a roller-bandage, and require it to be wmt with water 
about every four hours. This dressing remains undisturbed 
for a period of forty-eight hours, when I remove the bandage, 
and compress with much care, lest I might displace the grafts, 
but the plaster is not disturbed. The transparent character 
of the plaster used enables me to see the changes which have 
taken place beneath it. The ulcer should now be carefully 
cleansed with water, and a similar dressing reapplied. 
Whether the ulcer ought to be dressed daily or every 
second day, will depend on its condition; but the plaster 
should remain undisturbed for a period of six or eight days. 
The planting of normal germs, or what is more familiarly 
called skin-grafting, has been to me a subject of great interest, 
and I have spent much time in the study of this interesting 
and successful mode of healing ulcers. The more common 
mode of germ-planting consists in taking from any part of the 
patient's body a piece of healthy skin, which is then divided 
into many small pieces, and these small pieces, varying in size 
from the number four to number eight shot, are then placed 
on the surface of the ulcer. In watching the result of this 17 
operation, I have frequently witnessed phenomena which, at 
that time, I think had not been explained. It is the rule to 
allow the grafts to remain undisturbed for several days, al- 
though after the first forty-eight hours I have usually removed 
the dressing daily, for the purpose of watching the progress 
and cleansing the ulcer. It often happened that every trace 
of the grafts so recently applied had entirely disappeared, or 
at least wrnre not discernible to the unaided eye. This ap- 
pearance was deceptive and not real. Within a few days 
there would appear on the site of each graft a grayish-white 
speck, which would rapidly increase in size, and serve as a 
new point of cicatrization. In what did these phenomena 
consist ? The germ-theory gives me a satisfactory solution 
of the question. The formed material had undergone putre- 
factive solution, and the germinal matter, having found a soil 
congenial to its wants, had taken root, to bring forth a thou- 
sand-fold. The second method of germ-planting consists in 
removing the epidermic scales from some portion of the body 
— more frequently the thigh — which had been previously 
shaved to remove the fine hairs, after which the parts were 
scraped with a scalpel, and the scales collected on a piece of 
writing-paper, and these carefully distributed over the sur- 
face of the ulcer. The same phenomena were here observed 
as in the first method, although less satisfactory results on the 
ulcer were obtained. The third method consists in applying 
a fly-blister to some portion of the body—collecting the serum, 
transferring it to the ulcer, and retaining it in contact. Here, 
again, good results have been attained, for the reason that the 
serum contains living germinal matter. The chamois-skin 
was used for the same purpose; but its use in every instance 
proved to be a miserable failure, for the reason that the ger- 
minal matter in the old skins was dead, and that dead seed 
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