Imatges de pàgina
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must, however, be allowed, that in the extremely acute forms of this disease, the most soothing applications to the surface of the skin are indispensable, and that fomentations and poultices, for twenty-four hours or longer, may be quite necessary. But I would say that as soon as the plaster can be borne it ought to be applied without delay. It is likewise to be remembered that there are idiosyncrasies where a plaster, entirely unirritating under ordinary circumstances, cannot be endured, from the cutaneous irritation and excitement which follow its use. This, of course, is to be regarded as an exception to a rule.

The mode of application is the following. After spreading the plaster in the ordinary manner, it is to be cut in dimensions according to the size of the carbuncle or boil to be dressed; carefully observing that it is large enough to include from half-an-inch to two or three inches of the surface around the tumour. Where this is large and deep, as in a carbuncle from four to six or eight inches in diameter, the circumference to be embraced should be proportionately large; and the leather, in such a case, should be chosen soft and strong, in order to obtain an amount of adhesive mechanical support to the surrounding and subjacent parts, so as to enable them to originate and establish a new action. It must be well remembered that it is not enough, in any of these dressings, to cut the plaster the exact size only of the tumour. It is expected that some of the surrounding surface should be taken in also. In twenty-four hours after dressing, favourable change in the appearance of the parts is generally discernible; and-what will be allowed to be a highly important result, in those cases where the local irritation is fast inducing a state of cerebrospinal distress and lesion, likely soon to end in coma and death-it will often, in a less period of time, afford a mitigation of suffering which comes upon the patient like a charm, and restores him the rest and sleep to which he had long been a stranger. If the tumour be prominent or pointing in any part, a crucial incision is to be cut in the plaster, and placed directly over it, that the discharge may have free egress; and should there be at first no suppuration, this mode of dressing quickly promotes it, and assists the living parts to detach and throw off, at the least possible loss, the sloughy cellular membrane. If the tumour is not disposed to slough or suppurate, the application decidedly hastens the resolution or absorption of the effused matter.

In a boil the dressing is precisely the same as in a carbuncle; taking care that the plaster has sufficient hold of the tissues around-perhaps from half-an-inch to an inch. In a few hours, the acute pain and suffering of the patient, which had unceasingly disturbed his rest and comfort, become greatly mitigated, and soon afterwards wholly removed; and the improvement in the condition of the parts is strikingly apparent on every renewal of the plaster. The little trouble and inconvenience of this method, both to patient and surgeon, strongly contrast with the inconvenience, wearisome labour, and attention required by the old plan; and whilst the latter necessarily confines the patient, even in minor cases, to the house, in bed, or on a couch, the former will often be little or no restraint on his usual avocations. It is requisite that the plaster be changed more or less frequently, according to the extent of discharge or slough; but the longer the interval the more desirable, as the less the parts are disturbed the better. If there be much discharge or slough, soiling the cut edges of the plaster, it may be changed once a day; if there be little, every third or fourth day will be sufficient; but the linen pledgets and bandage adjusted over the plaster, and absorbing the discharge as it exudes, may be replaced frequently. In general, no other dressing is required to the end of the treatment. The plaster must be reduced in its dimensions as the tumour lessens in size, whether it be by suppuration, slough, or absorption. In some instances towards the close, simple or calamine cerate may be desirable. The solution of the nitrate of silver, of the strength of 3i. to 3i., will also be found of great value as a cicatrizer; for I concur with my friend Mr. Higginbottom that, besides other valuable properties, which he has so ably advocated, there is no agent in surgery so useful for promoting healthy cicatrization or removing excoriations as lunar caustic. It likewise excels all other means in giving increased vigour and strength to a new cicatrix. From what I have seen of this method of treatment in a number of patients during the last several years, and from the speedy relief or total removal of pain and distress in the worst cases, and in bad temperaments, I have looked upon it as of great value, if attentively carried out; for I am persuaded that it will render recourse

either to the knife, to caustic remedies, or any of the other more severe measures of our art, unnecessary. Should, however, the choice of the surgeon and patient lead them to the latter alternative, I would strongly enforce that, whether it be the knife or the caustic, it be always used at an earlier stage of the disease than is yet commonly practised, as this, like the early free incision in diffusive inflammation of the cellular membrane, will prevent the destructive ravages of tissue, as well as the fatal constitutional symptoms which follow the unchecked and protracted course of the disease. Association Med. Journal, July 15, 1853, p. 696.

117.-ON THE TREATMENT OF INDOLENT ULCERS BY INCISIONS. By JOHN GAY, Esq., Surgeon to the Royal Free Hospital.

[In the employment of his bandage, Mr. Baynton considered its chief value to be from the pressure which the ulcer received from it, and especially as tending to bring the edges of the ulcer closer together. Mr. Critchett, in his work on ulcers, condemns this view, believing the value to arise from the support given to the circulation in the veins, especially if they happen to be diseased.]

Mr. Baynton's plan of bandaging, with the view of bringing the edges of the ulcer closer together, and Mr. Critchett's, for the purpose of giving support to the limb, have equally been successful, and have as often failed. The anomaly therefore remains, from which the following question arises: Why does bandaging fail of curing an ulcer when à priori there was every reason to expect that it would have induced its cicatrization? The author believes that it arises entirely from a nonrecognition of the principles upon which all ulcers must be treated in order to insure their cicatrization, and of the real part the bandage must take whilst carrying these principles into practice; and he observes that the end which the surgeon should have in view should be to give freedom to the edges of an ulcer, that they might be enabled to contract, as well as freedom to the adjoining tissues, that these might yield to the traction thus made upon them. It is now plain how pressure can promote the healing of certain sores, but that it can only do so mediately, and this by removing any condition of the edge and adjoining parts that might be unfavourable to that process. It cannot, however, as is supposed, promote the immediate act of cicatrization, but on the other hand (if it has any influence at all on the process), retards it by the restraint which it is calculated to place upon the movements of the skin. The bandage, however, can be applied so as directly to favour the act of cicatrization; but this it can only do when used as Baynton applied it—i.e. in such a manner that it shall "bring the edges of the ulcer nearer together." The author related the case of a lady who had a small varicose ulcer over the inner malleolus, surrounded by a broad patch of eczematous skin. He tied the veins, placing a ligature on one close to the edge of the sore, within the area of the diseased skin. The ulcer healed, and with it all the wounds made by the ligatures, except that near the cicatrix of the ulcer, which remained open, having the same indisposition to heal as that manifested by the original sore. Another ligature was applied to a vein observed to be running towards this sore close to its edge. The same results followed; the ulcer healed, but the sore made by the ligature gaped, and became an indolent and apparently an incurable ulcer, for it resisted every effort to induce it to heal. After a few weeks the whole leg was attacked with erysipelas, and vesication ensued over the diseased portion of skin. On the subsidence of the inflammation, the skin assumed its former healthy condition, and the ulcer immediately healed. The author thinks it clear that the obstacles to the entire and permanent healing of these indolent ulcers are to be found directly in the condition either of their edges or of the adjoining tissues, or in that of both conjointly-i.e. the edge of the ulcer is not free to contract, or the adjoining textures are not free to yield to the traction that the edge, in closing in, makes upon them. The treatment he proposes will be gathered from the recital of the two following cases:—

Case 1.-E. F., aged 36, a seafaring man, was admitted into the Royal Free Hospital for an extensive ulcer on the front and lower part of the leg, consequent upon a blow received seventeen years since. He had been an inmate of many hospitals, and the sore had on as many occasions readily yielded to rest and treatment up to a

certain point; but after diminishing to the size of a shilling, or rather larger, the process of healing became invariably checked, and no means could bring about complete cicatrization. On resuming his usual occupation, the ulcer invariably began to spread; and, in despair of obtaining a cure, the poor man requested that his limb might be amputated. Instead of acceding to his request, Mr. Gay had him placed in bed, and the ulcer treated with water dressings. It began to granulate, and to close in, but after a while this process again suddenly ceased, and in despite of strapping, bandages, and topical applications of all kinds, refused to proceed any further. On careful examination, Mr. Gay observed, that at the part where the ulcer was situated, the leg was less in size for a space corresponding to little more than the longest diameter of the cicatrix, as though, in that particular part, it had been surrounded by a tight bandage. The skin itself immediately around the sore, instead of being elastic, and free to glide over the subjacent tissues, was tense and iminovable, although in other respects apparently healthy; and any attempt to draw the edges of the sore nearer together was thereby rendered futile. Mr. Gay, therefore, made an incision through the healthy skin and superficial fascia of the length of the whole cicatrix, within a short distance of the edge of the sore, and in a direction parallel to the long axis of the limb, and therefore at right angles with the line of principal tension. The wound first gaped a little; the ulcer, however, began immediately to close. On the third day, the wound gaped still more; and it was interesting to observe that the edge against the ulcer followed exactly the outline of its edge as the latter varied in the course of healing-manifestly the result of the traction made by the edge of the ulcer upon that of the wound. After the fourth day, by which time the sore had almost closed up, the process of healing was less rapid; but within twelve days cicatrization was complete, and in another twelve days that of the supplemental sore was likewise accomplished.

Case 2.-A. B., aged 29, a domestic servant, had a sore on the inner malleolus, of the size of half-a-crown. It had existed for twelve years, and was supposed to be due to large varicose veins, which were to be seen running down the leg towards the ulcer. On three separate occasions Mr. Gay tied the veins, and the operation, with rest, appeared to be successful. The ulcer, however, re-opened on each occa sion shortly after her return to her work. On examination, it was observed to be shallow, and disposed to heal, whilst its edges were hard, and immediately fixed to the subjacent tissues. Towards the heel the adjoining skin was a little thickened, of a purplish colour, and also fixed; but in the opposite direction, immediately beyond the edge of the ulcer, it was perfectly healthy, and very loose.

It will now be obvious that in some important respects this case differed from the foregoing; for, whereas in this the edges of the sore were free, but the adjoining skin fixed; in the one under consideration the edges were fixed, but the adjoining skin on one side was free. This ulcer was, therefore, treated in the following manner:-After excising it entirely by means of incisions close to its edge, Mr. Gay made two other incisions parallel to the edges of the new sore, and about an inch from them through the adjoining skin. The portion of sound skin towards the surface of the foot, included between the sore and the front incision, was then dissected from its adjacent connections, shifted over on the site of the ulcer, and its edge united to that with which it was now brought into contact by means of harelip needles. The incision towards the heel was left for the same purpose as that for which the analogous incision in the former case was made-viz., to relieve tension. By the fourth day the transplanted flap had united to the base of the sore, and, with the exception of a very trifling slough of a portion of the opposite edge around the needle, all was going on perfectly well. This case is given so far as an illustration of the practice which Mr. Gay thought proper to adopt in accordance with the principles advocated in the foregoing remarks. A severe attack of typhus fever overtook this patient, and with its accession the reparative processes, which had been going on most satisfactorily, were interrupted for a time. These, however, have since been satisfactorily renewed, and the flap of healthy skin which supplied that lost by ulceration is becoming reunited to the base of the sore, and will yet take an important part in the future stability of the cicatrix. The plan of treatment which Mr. Gay suggests for ulcers, which he says appear to defy all other methods, is now obvious. It is, to relieve the tension of the adjoining skin or other

tissues, where that is opposed to the healing of a sore, by incisions at right angles with the apparent line of tension, as in the first case; or by a species of plastic operation to supply new skin altogether, where the obstacle to its formation lies in an irremediably fixed condition of the edge of the sore itself, as in the second.— Lancet, June 18, 1853, p. 568.

[In a letter to the editor of the Medical Times and Gazette,' Mr. H. T. CHAPMAN, after commenting upon the above operation, proposes the following modification, which he considers to be simpler in its performance, and obviating the danger of producing one or more ulcers by the incisions practised by Mr. Gay:]

The plan referred to consists in simply raising the adherent skin from its connexion with the parts beneath, by gliding a double-edged bistoury under the tense margins of the sore, so as to set thein free to a sufficient extent to admit of their edges being brought nearly, if not quite, into contact, across the suppurating surface, my intention being afterwards to maintain them in that position by short straps of adhesive plaster, until union had taken place. A further division of the raised margins, at right angles to the sore, may sometimes be requisite for their better adjustment.

Its feasibility not having, then, been tested, I did not think it worth while to allude to what was no more than a project in the second edition of my Essay on Ulcers, published in the early part of the present year; but spoke of it to a number of friends attached to hospitals, in the hope that some of them might be induced to give it a trial. This has been done recently, under the influence of chloroform, by Mr. Ure, at St. Mary's Hospital, although my views were not entirely carried out, the after treatment consisting merely of water dressing and rest, no effort having been made to draw together the liberated margins with adhesive plaster. The latter stage of the cure was accordingly completed by granulation, and occupied more time, I imagine (about a month), than if the straps had been employed. Its success, nevertheless, has been sufficiently marked to encourage its repetition in other cases, a notice of which will, in all probability, ere long

appear.

One word of caution in conclusion. A tendency will always, perhaps, prevail to adopt and practise these and similar novelties without due discrimination. I have already been asked my opinion as to the propriety of an operation in two instances where no shadow of a necessity existed for any measure of the kind. The margins of neither ulcer were more than ordinarily adherent to the parts beneath, nor could I discover the least tension of the surrounding skin. Both sores, in fact, afterwards healed under long established methods of treatment.

The cases are extremely few in which an operation is indispensable; and still fewer, I suspect, are the private patients who will submit to the treatment of an ulcer on the leg by the scalpel, even when all other attempts have failed.—Medical Times and Gazette, Aug. 13, 1853, p. 176.

118. ON THE TREATMENT OF ULCERS BY GALVANISM.

By T. SPENCER WELLS, Esq., H.M.S. Modeste.

[Having had repeated opportunities of witnessing the effects of a single current on ulcers and granulating surfaces, Mr. Wells thus records the main point of his experience. He says:]

The apparatus I have used has been of two kinds. The first is a single pair of plates, namely, an oval plate of zinc from one to three inches in the long diameter, and a plate of pure silver of the same size and form, the two being connected by a silver wire soldered to the back of each plate. The second I have only used for about a year. It is Pulvermacher's electric chain, which I have used with six and eighteen elements. I shall first state the result of my experience with a single pair of plates, subsequently remarking upon the comparative influence of Pulvermacher's chain.

1. To secure the effects of the apparatus, it is necessary that the surfaces of the two metallic plates be perfectly smooth and clean, and that they should be applied to the body without intervention of any substance whatever. At first I believed that. XXVIII.-16.

it was necessary to denude the cuticle; and accordingly, when I required to act upon an exposed surface, I applied one plate upon it, and made a small puncture in some neighboring part, upon which the other plate was applied. I soon found that this was unnecessary, and that it was only necessary to moisten the cuticle to insure the passage of the current. When moistened by vinegar, or an acid solution, the effects were quite as rapid as after the denudation of cuticle.

2. If two slight excoriations, two ulcers or suppurating surfaces, upon a limb or any part of the body, be acted upon by a pair of plates, the zinc being applied upon one, the silver on the other, the surface beneath the silver rapidly cicatrizes, while that beneath the zinc is in two days converted into a superficial eschar. If the plates be still kept applied, the eschar extends to the subcutaneous cellular tissue, and presents all the characters of a slough produced by caustic potash, except that the dead tissues are a little less compact. After the separation of these sloughs, cicatrization under ordinary applications is very tardy, but is much hastened by the application of the silver plate, the zinc being fixed on some neighbouring part. So long as the zinc plate remains upon an exposed surface, a copious exudation of fetid serum goes on from it, and a dark, soft, spongy slough is produced, which does not clear away for two or three days after the zinc is removed. After the separation of the slough, an excavation is left, and the granulations are healthy. They reach the surface level much more quickly when the silver plate of the apparatus is employed, than under any other treatment. That this good effect is not due to mere pressure of the metallic plate I have become convinced, after comparative trials of the application of the silver, with and without connexion with zinc. I have made numerous trials of the methods of Baynton and Scott, of water and dry dressings, of elastic bandages, and various other accepted modes of treating ulcers, and have found no means so capable of uniformly producing a rapid growth of healthy granulation as galvanism.

3. I have often been astonished at the change effected in twenty-four hours in the condition of ulcers. At one dressing they are seen to be deep cup-like excavations. At the next the granulations have nearly reached the surface. On the third day the surface level of the skin and granulations of the skin are often uniform, the wellknown marginal blue rim announcing the commencement of cicatrization. When this point is attained, it is better not to apply the apparatus again, but to employ simple water-dressings, or, if there be any tendency to flabbiness in the granulations, dry lint, and a strap of adhesive plaster. When I was assistant-surgeon in H. M. S. Hibernia, a form of contagious circular sloughing ulcer was very prevalent. We used to destroy the diseased surface by undiluted nitric acid, and apply the galvanic apparatus as soon as the slough separated. The men were often allowed to walk about, and suffered no more impediment from the apparatus than from a simple bandage. Much trouble was spared in dressing, as the apparatus was only removed once in twenty-four hours. In that very obstinate form of ulcer naval surgeons are so frequently called upon to treat, called by the men "a burn with a rope," in which coils of rope, twisted round a limb, destroy a ring of integument, fascia, and perhaps muscle, the slowness of the natural process of repair under any variety of ordinary treatment is quite peculiar. I treated a case of this kind when surgeon of H. M. S. Trafalgar. The integuments, fascia, with some portions of muscle, were destroyed all round the calf of the leg; the tibia and fibula being laid bare. The slough separated, and an annular ulcer remained nearly two inches in breadth. The man was a long time on the sick list before I applied the galvanic apparatus. Scarcely any signs of a reparative process had appeared when I applied the silver plate of the apparatus to a portion of the ring; and it was quite extraordinary to trace the daily effects as the plate was moved around the large ulcerated surface; the spots where the silver had been applied for only twenty-four hours being far above the level of other parts, and consisting of small conical granulations, in place of the flat, flabby surface which had formerly existed. Cicatrization afterwards took place as readily as in ordinary cases.

4. When the zinc plate is applied upon the superior portion of a very large ulcer, this portion alone improves in appearance, while the inferior portion degenerates; but if the plate be applied upon the lower portion only, the whole surface of the ulcer improves equally.

5. In cases where several ulcers exist upon a limb, and the zinc is applied to a

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