Cure of an 'Ulcerated Leg' of Fully Thirteen Years' Standing

J. Cochrane
1877 BMJ (Clinical Research Edition)  
bandage is put over all, wide enough and tight enough to effect all that is required. The time for removing the sponge and undercovering of linen or cotton may vary from twenty-four to forty-eight hours (never longer), and the removal must be effected so carefully as not to cause any dragging on the flaps. If the linen or cotton be found to adhere to any point of the wound, I prefer leaving it where it is, quite dry, to bathing or tearing it off, and a snip with the scissors is all that is
more » ... is all that is needed for this. The linen is replaced by a clean bit, if all be found favourable, and the sponge is washed, wrung dry, and put on again, and left for two or tbree days, or even more, in order to make sure that the union is quite firm. The patient is kept in bed, and not allowed to move freely until the wound is healed. For three or four days, very meagre diet is allowed, and no stimulants in ordinary cases. Ligatures, even of waxed silk, do not generally produce irritation, as will be shown in the following case, which I give in support of what I have said. Three weeks ago, assisted by Dr. McWatt, I amputated the left breast for cancer. The patient was very stout and the gland large and embedded in fat, a considerable amount of which was removed after the tumour, because of infiltration and in order to admit of adjustment of the flaps. Seven waxed silk ligatures were applied, the edges were brought together with carbolised gut, and the wound was dressed in the way described above. On the second morniing, while removing the dressing for the first time, and just as I was finishing, the patient suddenly started aside, and thus caused the forcible separation of the linen from the axillary angle of the wound to which it was adhering. About a teaspoonful of blood followed, and I feared that mischief might be the result of this irritation. Next day, when I called, I found she had had a rigor after I left, and, on removing the dressing, I observed a faint blush over the inner half of the wound. I reapplied the dressing, and, in anticipation of erysipelas, prescribed twenty grains of sulphocarbolate of soda every six hours. Although there was a faint blush over part of the wound, Dr. McWatt, who was present when I removed the dressing, thought it looked like healing by first intention; and everything about the case, at this stage, certainly afforded more reason for saying that it htzd donie so than was found in that reported by Mr. Maunder at the same period after operation. Two days later, the linen cloth next the wound was damp, and, on removing the dressing and carefully examining the cicatrix, I found it healed and firm, save for about the third of an inch. To prevent reopening, I supported the flaps on each side of this unclosed spot with strips of adhesive plaster. A little thin pus continued to pass for a few days, but gave no trouble. Five ligatures have come away through the firmly closed edges without a drop of pus accompanying or following any of these, and the remaining two are clean and dry, thoug,h gentle traction is applied to each daily. The patient's pulse never rose above go, and she has never had the slightest pain, except when she gave the start when I was removing the first dressing. This is not a selected case, but I give it simply because it is the last I have had. I may further remark that, in minor amputations, I invariably place a bit of sponge right over the stump, and have hitherto found it of much service. T~~~~~~~~~~~~~~~~~~~~~~~~~~C THE following case, the details of which I now present, is a somewhat interesting one. When I commenced practice here (Colmonell), in April last, I was called to see a male pauper who had suffered for a long time from an ulcerated leg. On proceeding to the patient's house, I discovered the following state of matters. The leg affected was the right one; and about four inches above the ankle, on the outside of the limb, there was an ulcer, measuring five inches in length and three inches in breadth. The smell from it was something most horrible, and, on examining it more closely, I found the wound gangrenous. The limb, frona the knee down to tlle ankle, was very much swollen and the skin dark-coloured in appearance. Tlle foot also was much swollen and the ankle cedematous. T1ie ulcer at-o discharged continually much watery fluid. Its edges were exceedingly hard and the surface of a slaty-blue colour. Its depth was fully an inch, and conjoined with these signs was much pain in the affected limb. The pain at times was so severe as to prevent the man from getting sleep at night. The history of the case, obtained from the man and his wife, was as follows. Fully tiirteen years ago, the limb was attacked with an inflammatory form of disease; the symptoms, as described to me, warranting the supposition that it was erysipelas, the result of an injury to the leg. Since then, numerous little ulcers had appeared at different parts of the limb, and had disappeared under treatment, such as it was. Then a large ulcer formed on the anterior aspect of the limb, and, healing at one spot, spread over the limb till it settled in the part which was now affected. At the same time, the leg began to swell and become dropsical. For some years, the mani continued to work at his employment,which was a laborious one; and then, when he found the leg becoming worse, he applied for relief from the parochial board. When I saw him for the first time, his leg was as hard as a stone from the knee to the ankle. He said that this hardness had been present for a considerable period, and the limb now was almost three times the circumference of the neighbouring leg and much heavier. There were a few varicose dilatations of the veins near the knee; but what struck me most was this same hardness of the tissues and the blackened appearance of the skin. The skin also, from the knee downwards, was affected with psoriasis. This latter, no doubt, was due to the continual irritation from the nasty discharges coming from the ulcerated surface, and from the venous obstruction, which also undoubtedly was the cause of the cedema of the ankle and foot. Possibly, also, the condition of the blood was at fault, owing to the neglect which had been shown to the treatment of the ulcer. The man had never been put under suitable treatment, ani all sorts of absurd applications had been made to the ulcer on the recommendation of friends. At one time continual poulticiing was used, which, he said, however, never failed to remove the pain for a time. Then my predecessor here, the late Mr. Wilson, who acted on the homoeopathic system, prescribed some drops, which, of course, did no good either to relieve pain or help tlle curing of the sore leg. At one time, also, the man was sent to Glasgow Infirmary at the expense of the parish, on the suggestion of a member of the board and with the concurrence of the parish doctor. There he was told by one of the surgeons that it was a hopeless case; and, seeing that there was little prospect of a cure, heleft the infirmary and returned here again, to be informed by the parish. doctor " that there was no chance of effecting a cure", and that, even if it were possible, it would be dangerous to attempt it. Such is thehistory of the above case, and I believe the man's statements to be true; inasmuch as he enjoys the character of being a truthful and honest workman, and most of. the inhabitants of the district know well how he has suffered so long. I diagnosed the case to be one of what is called "diffuse hypertrophy of the skin and subcutaneous connective tissue", or "pachydermia". The ulcer was merely a concomitant. The Treatment I adopted, and it has been so far successful as to reduce the size of the leg, cure the ulcer, remove the dropsical swelling of the foot and ankle, and improve the condition of the skin, lasted over a considerable length of time, nearly five months. First of all, I determined to attack the ulcer and bring it into a healthy condition. I used at the commencement, as a dressing, a diluted solution of permanganate of potash applied on lint, which at first was changed twice in the day. After a few trials of this, I resolved to apply a solution of carbolic acid, inthe proportion of about two drachms of the acil to eight ounces of water, along with a little glycerine. This soon told on the sore, as it soon commenced to granulate and new skin to form gradually. Very hot weather setting it, I discontinued the watery solution of carbolic acid, and used instead an oily solution of the acid mixed with glycerine, and this did remarkably well. Occasionally, slight venous oozing appeared at the surface of the ulcer and around its edges ; but this was counteracted by the application of a solution of zinc sulphate. Soon the wound began to fill up, the hard edges to disappear, and, after a protracted period of over several moulths' duration, the ulcer entirely healed over. But from the very commencement, I adopted the measure of bandaging the limb from the foot up to the knee, and this was done daily, and often twice in the day, with few exceptions. The man was also kept as much as possible in the recumbent position, with the foot slightly elevated and the limb laid on a pillow. I also gave him internally iodide of potassium in five-grain doses, combined with bichlorideof mercury, one-twelfthofa grain, in compound decoction of sarsaparilla, and the compound tinctures of cinchona and of cardamoms. This he continued to take from the first, and occasionally mild symptoms of iodism were produced, but the dose was easily stopped. This dose of the above drugs he took thrice daily, and at the same time occasional doses of saline purgativesweregiven to keep the bowelsregular. When the ulcer healed, I used, for the psoriasis, the inunction over the affected skin of, first, carbolic acid in solution with oil and glycerine. Then I afterwards tried benzoated oxide of zinc ointment, the nitrate of mercury ointment diluted with lard, etc., and latterly used nothing, but simply bandaged the leg. The leg is now almost as well as its neigh-
doi:10.1136/bmj.1.837.40 fatcat:ga2yrt5vbfc7bp2i4khx7q5xsa