strips to just below the ulcer, above which other strips commence, the latter being the looser. The ulcer itself is thus left bare for the application of the dressing, over which farther strips are daily placed. The advantage of this is, that the ulcer can be got at without disturbing the greater portion of the strapping. I know not what will be said by some gentlemen, when I own to the weakness of at times resorting to a poultice. Yet it has appeared occasionally to give relief, even when water-dressing has failed. When the sore is irritable and inflamed, one of bread and water, or of bread and Goulard water, laid on at night with a piece of oiled skin over it, has been productive of much comfort. At the same time, it is only fair to admit, that poultices may be grossly abused, and as ordinary applications are useless, or worse. When the sore is sloughy and inclined to phagedæna the opium poultice is invaluable. In that inflamed condition of skin to which allusion has been made, goulard water applied through the medium of rags, or a bandage covered with oiled skin, commonly gives much relief. It does not seem to agree so well with the ulcer itself, which may be dressed in the ordinary way. It is needless to observe, that for cases such as these, rest is particularly requisite. Such are the few observations I would make upon the local treatment. Possibly a few may also be permitted on the general. Of course it is requisite to attend to the state of the secretions. If the stomach, the liver, the kidneys, should be out of order, such medicines should be given as are calculated to restore their functions. It would be impertinent to dwell on them. Of the value of purging there can be little doubt. Where the tongue is loaded and foul, with but moderate or impaired constitutional power, a condition very common amongst out-patients, bitter purgatives agree. The infusion of gentian with the tincture, and some sulphate and carbonate of magnesia, form a good though nasty compound. In females, with defective menstruation, or, at a later period with impaired digestive powers and low tone, the compound decoction of aloes, with or without senna, is useful. Tonics are, in most cases, required after purgatives or with them. Circumstances must determine their selection. In cachexia, mercurial or otherwise, sarsaparilla bears the bell. Quina, gentian, steel have their several applications. A cheap and a good tonic in persons with a weak circulation, and not disposed to cerebral congestion, is the compound steel pill. It is a great favourite with my excellent colleague, Mr. Cutler. But there are very many cases in which the compound soap pill acts admirably. Elderly persons, with a varicose condition of the veins of the lower limbs, a languid pulse, and a feeble and not excitable habit, are sometimes wonderfully bettered by it. Nor does it appear to affect the head or constipate the bowels, so much as might have been anticipated. The dose may be three grains twice or thrice daily, and senna or aloes may be taken in the morning for the bowels' sake. I am not so sure that this medicine suits the young or middled aged-undoubtedly it does not suit so well. It is apt to distress the head. In one woman between 20 and 30 years of age, disposed to flushed face and to cerebral fulness, it aggravated the latter to such a degree as to compel its discontinuance. In the cases I have selected for it, it is a valuable remedy. With these observations, I will now take the liberty of giving the brief particulars of two or three cases intended to illustrate them. They have been drawn up by my brother, Mr. Athol Johnson, who has acted as Clinical Clerk. They are mostly in the condensed form of Report, and have been selected merely as samples, from amongst a considerable number. CASE 1.-Old Varicose Ulcer-Comp. Soap Pill and Lotio Zinci SulphatisCure.-Hannah Sadgrove, æt. 27, applied at St. George's Hospital, on the 18th of January, on account of a large varicose ulcer of the leg of long standing; a variety of medicines were administered, and poultices, ointments, &c. applied, without any benefit. On the 28th March, the notes state that there was "no improvement: sores sloughy." Three grains of the compound soap pill were ordered to be taken three times a day, and the lotio sod. chlor. and afterwards the lotio zinci sulph. applied locally. On the 19th of April, the patient was discharged, cured, the ulcers being firmly healed. CASE 2.-Cachectic Ulcers of Leg-Comp. Soap Pill and Sol. Arg. Nit.-Cure. Catherine Bennett, æt. 30, servant. This patient applied at the Hospital on the 1st of Feb. with a cachectic ulcer of the leg, about the size of a crownpiece, which had first appeared about three months before; the veins of the extremities were also considerably enlarged. She was placed upon steel, with occasional purgatives, and a variety of applications, ointments, poultices, &c. were tried, without any apparent benefit. On March 25th three grains of the compound soap-pill were ordered to be taken daily, and a weak solution of nitrate of silver applied, under oiled silk, to the leg. The beneficial effect was immediate; the sore assumed a healthy character, which it never subsequently lost, and on April 23, the patient was discharged, cured, the ulcer having been for some time soundly healed. CASE 3.-Old Sloughy Ulcer-Comp. Soap Pill and Sol. Sod. Chlor.—Cure. Henry Butterfield, æt. 48, made O. P. Feb. 1st, 1843.-This was one of the worst cases of old sloughy ulcer, which had been seen at the Hospital for some time. It was of very large size, and there was great induration of the cellular membrane of the whole leg, with an extremely fætid discharge. The compound steel pill and other tonics were employed without any benefit. On the 4th April, there being then no improvement in the state of the ulcer, three grains of the compound soap pill were ordered to be taken three times a day, a warm bath twice a week, and a lotion composed of one part of liq. sod. chlor. to fifteen of water, applied under oiled silk. From this time a gradual improvement took place, and on May 16th he was discharged, the ulcer being quite healed, the cicatrix appearing good and healthy, and the induration nearly all removed. CASE 4. Very foul Varicose Ulcer-Gentian Mixture, and Sulph. Zinc Lotion-Cure. Mary Smith, æt. 47, washerwoman. Applied on the 12th April, with a painful varicose ulcer on the leg, of about the size of a shilling, with dark-coloured edges, and excavated surface, discharging foul and fætid matter. The health was much impaired. She was directed to take gentian with carbonate and sulphate of magnesia twice a day, and to apply the sulphate of zinc lotion (two grains to the ounce) under oiled silk. The sore immediately improved in appearance, and by the 18th May was quite healed. She was subsequently attacked with pain in the head, rendering it necessary to cup her, but the ulcer remained healed. CASE 5.-Old Varicose Ulcers-Gentian Mixture and Opiate Lotion-Cure. Harriet Pukett, æt. 40. This woman had been suffering from very large varicose ulcers of the legs for a long time when she applied for relief at the Hospital, about the beginning of February, the ulcers were in an indolent condition, and had then existed for about eight months; the health was also considerably impaired. Bitter purges, tonics, &c. were tried, and a variety of ointments applied to the sores, without much benefit to the ulcers, the report on the 28th March being that "the granulations were livid and flabby.' The compound soap pill was then ordered, but this affected the head so much that it was necessary to leave it off. Gentian with carb. magnes. and sulph. mag. was then tried, with the sulphate of zinc lotion, and afterwards Goulard water, both these appli دو cations, however, gave so much pain that they were omitted, and on April 23, a solution of opium, (gr. ij. ad 3j.) was substituted. On the 4th of May, the ulcers were all healed. CASE 6.-Cachectic Ulcerations of both Legs, of long standing-Tonics, Blackwash and Sol. Sod. Chlor.—Cure. Benjamin Bennett, æt. 42, applied at the Hospital on the 26th April, with cachectic ulcers on the front of either leg, some of which were as large as a crownpiece. There were also scars on the forehead, &c. of other cachectic sores, and the remains of destructive ulceration of the soft palate. Three years before this he had a sore on the penis, for which he was freely salivated; about a year afterwards he was attacked with sore-throat, &c. which had continued, off and on, up to the time of his application at the Hospital. He was ordered to take the haustus cinchonæ, with pot. iod. gr. v, twice a day, the bowels were kept moderately open, and the lotio nigra applied to one leg, the sol. sod. chlor. to the other, under oiled silk. On the 2nd May, the granulations were florid, in some ulcers even exuberant. There was no great difference in the progress of the two legs. The granulations were kept down by means of the argenti nitras, and on the 1st June, the patient ceased to attend, the sores on both legs being quite healed. Every surgeon is aware that both the simple and vaginiform bursæ, but more especially the latter, are liable to be distended not only with an increase of their natural secretion, but also with numerous small and separate bodies, oval or rounded, and frequently bearing a close resemblance in their form to melon-seeds. On the Continent, they have been considered as allied in nature to hydatids, but the prevalent, and more probable opinion, in this country, regards them as merely lymph broken down and rounded by attrition in a fluid medium. One of the cases, which will be detailed, appears to lend a strong confirmation to that idea. My object, however, in touching on the subject, is rather connected with the treatment of the disease, and the propriety of resorting to the knife. When the bursa is simply filled with fluid, with or without thickening of its parietes, blistering and pressure are commonly effective in reducing the enlargement. The same means, no doubt, may frequently succeed in procuring the absorption of effused lymph. But when this is disintegrated, and the "melonseed" fragments have been formed, it is questionable, alike in theory and fact, whether any applications on the surface can exert much influence on them. Now, as bursæ in this state occasion a good deal of annoyance to the patient, it becomes a question whether an incision with the view to the removal of the bodies can be recommended. Although it has been recommended and performed, there have occurred so many instances of subsequent inflammation and suppuration, that the experience of surgeons is against the step. It is fair to suppose that the danger is this :-a cavity is opened, which is prone by the nature of its tissue (a synovial one) to suppurative action-pus is secreted-it gets no free vent-and hence the mischief. If this be so, it follows that the more complex and ramified the sac, the more imminent the risk. The sub-cutaneous simple bursæ, such as that above the patella, would be favourably placed for an incision-the deeper simple bursæ, or the vaginiform, would be unpropitiously circumstanced. And such, I should say, is the fact. The suprapatellar or olecranal bursa may be laid open, with comparative, though not always, absolute impunity-the scapular, trochanteric, carpal and tibio-tarsal bursæ may not. The risks, in fact, that wait on meddling with these latter, are great. In two instances, I have witnessed extensive suppuration within it and around it, confinement of matter, extreme constitutional irritation, and fatal secondary inflammation from making an opening into the bursa, enlarged and filled with fluid, over the inferior angle of the scapula. In three instances, I have seen wide-spread suppuration in the fore-arm, from incision of the vaginiform bursa in the wrist, connected with the flexor tendons. We had lately a patient in the hospital, in whom this bursa was much enlarged, and presented a swelling in the palm, communicating under the transverse carpal ligament, with another in the lower part of the fore-arm. Fluid could be pressed from one swelling to the other, and, I think, there was the crepitation indicative of lymph. An incision was made into the palmar swelling-much inflammation and suppuration in the fore-arm followed, and the patient, of her own will, quitted the hospital, in a very dangerous state. I have not heard the result. But though, as a general rule, it is inadviseable to make an opening into the vaginiform bursæ, and the deeper-seated simple ones, it would be going too far to prohibit such a measure altogether. The inconvenience may be such as to justify the encounter of some risk-or suppuration may be actually occurring or established in the cavity. Besides, it may happen that the bursa has been incautiously punctured, mistaken, perhaps, for something else, or supposed to contain only fluid, when the "melon-seed" bodies, &c. are within it. It becomes then, a desideratum to determine, if a puncture is to be made, what sort of a puncture that should be, and what steps are to be taken to obviate the dangers which any puncture may give rise to. It appears to me that, if we do make an opening, it should be a free one—an opening which may not only discharge the actual contents of the bag, but render confinement of the pus that is to form impossible. No half-measure can be safe-lodgment of matter must be prevented, not relieved. These sacs are as much disposed to form lymph as pus, and a moderate opening will be partially, at all events, hemmed round with the former. Whatever we may do afterwards will probably not retrieve this first false-step-some purulent accumulation will take place and if it does so, the risk of secondary inflammations is imminent. The following case may seem to support these observations. I would remark that the diagnosis, prior to the puncture, was uncertain. The gentleman, under whose care the patient was, previously to his application to me, conceived that the case was one of fatty tumor. The puncture with the exploring-needle determined of course the existence of fluid, but its clearness and facility of exit deceived me, and led me to imagine that it exclusively occupied the sac. This induced me to make the subsequent puncture more readily, and I experienced some surprise when the quantity of liquid proved not to exceed two or three drachms, the bulk of the contents being solid. However, the opening was made, and immediately, in accordance with the principles that have been stated, I enlarged the incision to fully two inches, and introduced between its edges such a dossil of wet lint as kept them effectually asunder. The result appears to have stamped the propriety of the practice. There is little doubt that the bursa was that connected with the tendon of the gluteus maximus. This stretches beneath the fascia lata. It was in this instance of large dimensions, nearly capable of holding a fist, and when the masses of lymph were made to tumble out of it, the look of the thing was unpleasant. I am confident that, had matter once been confined there, the life of the patient would have been in great hazard. The process of transformation of amorphous masses of gelatinous-like lymph into the "melon- seed" bodies, was equally striking and obvious. The successive stages were apparent in the different portions. I now subjoin the case. CASE 7.-Wm. Weare, æt. 25, servant. Admitted April 19th, 1843, with a globular swelling about as large as a moderate-sized melon, superficially subcutaneous, but stretching deep, situated on the right buttock, above and behind the trochanter major. No distinct fluctuation, but feels rather like a fatty tumor. On bending the thigh, it becomes much more tense, prominent, and defined, and the fluctuation is much more evident. Skin over it unaltered; no pain. States that he first discovered the swelling, accidentally, five months ago; it was then of about the diameter of a crown-piece, and has gradually increased in size ever since. Knows of no cause. Has been attending as out-patient for five or six weeks, when the tumor was punctured with a grooved needle, and some yellowish clear fluid escaped. 21st. Punctured with lancet. Two or three drachms only of fluid escaped, the remainder of the contents consisting of the gelatinous sort of matter which is found in bursæ and vaginiform sheaths. Masses of considerable size, and irregular form; one, opaque and somewhat broken up, was apparently in process of transformation into "melon-seed" bodies. It was necessary to squeeze the cyst in order to get out the masses, some of which were left behind, and the opening was enlarged to 1 or 2 inches; a piece of wet lint was then introduced into the dependent extremity of the wound. Catap. panis calid. H. sennæ. 22d. No symptoms of irritation. Edges already granulating. Sac nearly empty. Some yellow opaque masses were squeezed out, consisting of portions which, with very little separation and attrition, would be "melon-seed bodies" or "hydatids." Vespere. Heat of skin, with foul tongue, and some pain. H. salin. efferv. 4tis horis. 25th. Has continued to have some little feverishness. There has been copious discharge, generally of thin yellow matter, but now rather thicker. Pain at times. No surrounding inflammation. Tongue still rather foul. Pil. hydrarg. Ext. coloc. comp. āā gr. v. h. n. May 2nd. Complains of severe pain across the forehead. Tongue still foul. Infus. ros. 3iss. Magnes. sulph. 3j. Acid. sulph. dil. mx. bis in die. Omitt. alia. Ordinary diet. 8th. Has lost the pain in the head. A little purulent discharge from the wound which is contracting. Health good. 24th. Wound now healed to a mere spot, furnishing only a little oozing. Discharged. |