ON THE APPLICATION OF THESE MODES OF TREATMENT TO PARTICULAR CASES.
I. OF PUNCTURES ETC.
In cases of recent punctured wounds the orifice and surrounding skin
should be moistened with a drop of water; the caustic should then be
applied within the puncture until a little pain be felt, and then over
the surrounding skin, and the eschar must be allowed to dry. In this
manner it is astonishing how completely the terrible effects of a
punctured wound are prevented; the eschar usually remains adherent,
and the case requires no further attention.
At a later period after the accident, when the caustic has been
neglected, some degree of inflammation is usually present, the orifice
is nearly closed with the swelling, and a little pus or fluid is
formed within. A slight pressure will evacuate this fluid, the caustic
may then be applied within the puncture, and over the surrounding
skin, beyond the inflammation, and must be allowed to dry. In this
manner we frequently succeed in forming an adherent eschar, and all
inflammation subsides. Any slight vesication which may be raised
around punctured wounds is not of the same consequence as when an
adherent eschar is wished to be formed over a sore or ulcer; one or
more small punctures may be made to evacuate the fluid and the part
may be allowed to dry.
If there is reason to think that an abscess has actually formed under
the puncture to any extent, it must be opened freely by a lancet and
treated with caustic and poultice, keeping the poultice moist and cold
with water.
In cases of puncture where the orifice is healed and where an
erysipelatous inflammation is spreading, attended with swelling, I
have applied the caustic freely over and beyond the inflamed parts,
and I have had the satisfaction to find that the inflammation has been
arrested in its progress and has shortly subsided.
This mode of treatment is particularly useful in cases of punctured
and lacerated wounds from various instruments, such as needles, nails,
hooks, bayonets, saws, &c. and in the bites of animals, leech-bites,
stings of insects, &c. In considerable lacerations the same objection
would exist to this treatment as in large ulcers.
The dreadful effects of punctures from needles, scratches from bone,
or other injuries received in dissection, are totally prevented by
this treatment. I have for the last five years had frequent
opportunities of trying it in these cases and have the most perfect
confidence in its success.
The advantage of these modes of treating punctured wounds will however
be best explained and established by a selection of cases, to which I
can add particular remarks as they may be suggested by peculiarities
in the cases themselves.
CASE I.
A.B. received a severe punctured wound by a hook of the size of a
crow-quill, which pierced into the flesh between the thumb and
fore-finger on the outside of the hand; scarcely a drop of blood
followed, but there was immediately severe pain and tumefaction. The
lunar caustic was applied without loss of time, deep within the
orifice and around the edge of the wound; and the eschar was left to
dry. The smarting pain induced by the caustic was severe for a time
but gradually subsided.
On the ensuing day, the eschar was adherent and there was little pain;
but there was more swelling than usual after the prompt application of
the caustic, owing to the mobility of the part.
On the third day the swelling remained as before, and there was a
little sense of heat. On the fourth day the swelling and heat had
subsided, and the eschar remained adherent. On the succeeding day the
eschar had been removed by washing the hand, and the puncture was
unhealed but free from pain and irritation. The caustic was
reapplied.
From this time the eschar remained adherent, and at length gradually
separated leaving the part perfectly well.
It is quite certain that under any other mode of treatment this severe
puncture would have greatly inflamed and have proved very painful and
troublesome; and it is not improbable but that suppuration and much
suffering might have ensued. All this is effectually and almost
certainly prevented if the caustic be applied promptly, as in this
case. When time has been lost, the case is very different as will
appear hereafter; but even in these cases, the caustic proves an
invaluable application.
CASE II.
Mrs. Middleton, aged 40, wounded her wrist, on the ulnar side, by the
hook of a door post; there was a considerable flow of blood at first,
but this ceased suddenly and the arm immediately became affected with
great pain and swelling. The lunar caustic was applied in half an hour
after the accident.
On the following day the eschar was observed to be adherent, and the
patient reported that she had suffered scarcely any pain, after the
smarting of the caustic had ceased. There was a slight swelling round
the puncture but that of the arm had totally subsided. The caustic was
applied over and beyond the swelling. On the third day all tumefaction
had subsided and there was no complaint whatever.
I hoped that this case would have required no further attention or
remedy. But my patient contrived unfortunately to rub off the eschar
about a week after its formation, and so to expose the subjacent wound
unhealed; she suffered however no pain or inconvenience from it; and
it was again shielded by means of a fresh eschar, which remained
adherent until removed by the healing process underneath.
This puncture was so severe that the arm was in a state of ecchymosis
for six or eight inches upwards, and I doubt not that without the
caustic, there would have been severe and long continued suffering,
and perhaps painful suppurations.
CASE III.
A female servant punctured the end of the finger by a pin; there
succeeded much pain and swelling, and it appeared that the nail would
separate, and the cuticle all round the finger was raised by the
effusion of fluid. This fluid was evacuated and a poultice applied.
On the third day the cuticle was removed, and the exposed surface was
found to be ulcerated in several spots. The lunar caustic was passed
slightly over the excoriated surface, which was then left exposed to
dry.
On the succeeding day the eschar was adherent and the pain had almost
subsided. On the next day, the eschar still remained adherent, and as
there was neither pain nor soreness, the patient used her finger.
The eschar was at length removed by the healing process and was
separated together with the nail, and the case was unattended by any
further inconvenience or trouble either to the patient or myself.
It is scarcely necessary to contrast the advantage of this mode of
treatment with that by plasters, poultices, &c. It is at once more
speedy and secure, and less cumbersome to such patients as are obliged
to continue domestic avocations.
CASE IV.
The present case is somewhat more severe than those which have been
already given, and what is of great importance, the caustic was not
applied immediately after the accident.
William Chantry, aged 50, received a stab in the wrist with a hay-fork
yesterday and applied a poultice; to-day there are great pain and
swelling, and the wounded orifice is very small. I applied the lunar
caustic within the puncture, and directly a cold poultice to be worn
over it; the arm was kept in a sling.
The next day the swelling and pain were diminished, and a little lymph
flowed from the wound. I again applied the caustic and continued the
poultice.
Two days afterwards, the swelling and pain were nearly gone. The
poultice was merely continued, the caustic not being requisite from
the subsidence of the inflammation. The patient came to me again in
four days more quite free from pain and swelling. The poultice was
discontinued, and the caustic was then applied in order to form an
adherent eschar, in which I was successful.
This case illustrates many important points; 1. it shows the efficacy
of the caustic with the poultice as a remedy against inflammation; 2.
it presents an instance of a labouring man returning to work on the
sixth or seventh day after a severe accident, even when the
application of the caustic had been unfortunately delayed; 3. it
points out the proper treatment, when all hope of the treatment from
the first by adherent eschar is lost from such delay,--for had this
been attempted in this case, suppuration would doubtless have taken
place from the closed state of the puncture by the swelling;--our
objects must therefore be, to open the puncture and to subdue the
inflammation, and these objects are admirably attained by means of the
caustic.
The following case is not less instructive.
CASE V.
Mr. Cocking's son, aged 12, received a stab in the palm of the hand
from a penknife three days ago, which has been followed by much
swelling and pain, the punctured orifice being nearly closed. I
applied the lunar caustic as deep as possible within the puncture and
directed a cold poultice to be laid over the whole hand.
On the next day I found that the poultice had not been applied; there
were more pain and swelling; an eschar was formed over the puncture
which I removed and thus gave issue to a considerable quantity of
pus; I again enjoined the application of a cold poultice kept
constantly moist and cold with water.
On the succeeding day, the inflammation had greatly subsided. I
repeated the application of the caustic and poultice. On the fourth
day the inflammation had nearly disappeared and on the fifth entirely.
In such cases the caustic unites the advantages of at once opening the
puncture and of subduing the inflammation, thus preventing the
formation of deep-seated abscesses.
CASE VI.
A little boy, aged 12, received a stab by a penknife a few days ago,
in the fore part of the thigh; there are now great pain and swelling,
the orifice is nearly closed, and he has feverishness with headach. I
applied the lunar caustic deeply in the wound, and directed a poultice
and a cold lotion to be kept upon the inflamed parts; and suspecting
fascial inflammation, I took away ten ounces of blood and administered
purgative medicine.
On the next day, the inflammation had greatly subsided; the cataplasm
and lotion were continued.
On the third day, there was some inflammation round the puncture which
appeared to be closing; I repeated the application of the caustic
within the orifice of the wound.
On the fourth day the swelling was subsiding and there was no pain.
The poultice and lotion were continued.--From this time there was no
occasion for any remedy, and the little patient speedily recovered.
CASE VII.
Mr. Parr, aged 30, of delicate habit, trod upon a needle which pierced
the ball of the great toe; a free crucial incision was made but the
needle could not be found; a poultice was applied to the wound and
over the poultice a cold lotion.
In the course of a week part of the needle came away. He did not rest
as he was enjoined to do, and, in consequence, severe inflammation
came on, and in two days time, fluctuation was perceived over the
joint, opposite to the puncture; a free incision was made, and some
pus was evacuated.
On the following day there was a free discharge, but very considerable
inflammation had taken place on the side of the ball of the toe; a
free incision was made in this part, and a fresh quantity of pus was
evacuated.
On the succeeding day, the inflammation was somewhat abated; but on
the next day, it had again become exasperated, and the openings made
for the evacuation of matter were somewhat closed by the swelling. I
now introduced the lunar caustic very freely into these openings, and
reapplied a cold poultice and lotion.
On the following day, I found that my patient had slept well for the
first time since the developement of inflammation, and had suffered
far less, after the smarting pain from the application of the caustic
had subsided, than before; the punctured orifices were open, and the
skin, which was extremely tense the day before, was become soft and
flexible.
From this time, I found nothing necessary but to repeat the
application of the caustic about every third day to subdue
inflammation and to keep the wounds open, which it always effected.
The joint ever afterwards remained stiff, from which we may infer the
violence of the inflammation; and when we consider what was the
constitution of my patient, we cannot, I think, doubt that the caustic
prevented many serious events usually consequent in such cases under
the ordinary treatment.
It is highly worthy of remark, that the good effects of the
application of the caustic, in this case, were too immediate and
distinct to be mistaken.
CASE VIII.
This case illustrates the mode of treatment by the lunar caustic, of
those terrible effects of punctured wounds which have been neglected
in the beginning.
B. Unwin, aged 40, washerwoman, applied to me on July the 10th, 1820,
with severe inflammation and ulceration of the middle finger, arising
from a puncture by a pin or needle some time before; there was much
painful tumefaction, and the integuments had burst along nearly half
of the length of the finger, on the ulnar side, and over the middle
joint on the radial side; the probe did not however pass to the bone
or into the joint. I applied the lunar caustic deep in every part, and
over the whole surface, and enveloped the finger in a cold poultice
covered with cold water.
On the 11th she reported that she had slept well for the first time
during the last fortnight; to-day there is scarcely any pain, but she
complains of soreness; the swelling has greatly subsided. The caustic
was again applied and the poultice and lotion continued.
On the 12th there were still swelling and pain; there was considerable
bleeding from the wound, so that I could not apply the caustic well.
On the 13th the swelling and pain were nearly gone. I repeated the
caustic which induced bleeding from the fungous flesh.
On the 14th the swelling had nearly subsided; the cuticle was
separating all over the finger. The lunar caustic was applied
extensively over the wound and abraded parts and induced little
bleeding or pain.
On the 15th the fungous was nearly removed; the wound presented an
appearance of slough over its surface.--The caustic was applied to the
remaining fungous.
On the 17th the wound was much smaller and the slough separating. The
caustic and cataplasm were applied as before.--A similar report was
made on the succeeding day.
On the 20th the slough was separating. The caustic and cataplasm were
applied.--A similar report was made on the 22d.
On the 24th the slough having separated the integuments over it were
flabby and loose; the caustic was applied to them.
By a continuation of this plan the wound gradually contracted, and, at
length, when there was no further use for the cataplasm, the eschar
became adherent and the sore healed underneath. It appeared highly
probable to me that, under ordinary treatment, the finger, in this
case, would have been lost.
* * * * *
I shall in this place, introduce a few observations on wounds received
during dissection.
It is not in my power to give any cases in illustration of the
treatment of the severer accidents resulting from these wounds; for
since I began the free use of the lunar caustic all the terrible
effects of such wounds have been invariably prevented.
I may here mention that in the years 1813 and 1819, respectively, I
was myself exposed to great danger from inoculation during the
examination of dead bodies. Since the latter period I have repeatedly
been exposed to the same danger from inoculation, but in every
instance, the danger has been completely averted by the prompt and
free application of the lunar caustic.
The following is the exact mode of treatment which I would adopt in
such cases.
In recent punctures the caustic should be applied in the manner
already described in cases of simple punctured wounds.
When the case has been neglected, a small tumour is usually formed
underneath the skin with smart stinging pain; this tumour should be
removed entirely by the lancet, and the caustic should be applied,
both to the surface of the wound and over the surrounding skin, to
form an adherent eschar.
When the case has been still longer neglected, and inflammation of the
absorbents has supervened, a free crucial incision is to be made, the
caustic is to be very freely applied, and afterwards a cold poultice
and lotion, the usual constitutional remedies being actively enforced.
* * * * *
In connexion with punctured wounds I here subjoin several cases of the
bites of animals.
CASE IX.
James Joynes, aged 12, was bitten by an ass, on each side of the
middle finger; the wounds were severe, and almost immediately
followed by swelling and great pain. The lunar caustic was well
applied within half an hour after the accident.
On the succeeding day, the eschar was found to be quite adherent, and
the pain and swelling had subsided.
The eschar separated in about twelve days and the wounds were healed.
CASE X.
Mr. Worth's daughter, aged six, was thrown down by a dog and bitten
severely on the face and forehead in three places; one of the wounds
in the cheek was deep from the penetration of the dog's front teeth,
and the parts were much bruised. The lunar caustic was well applied in
half an hour after the accident to each of the wounds, and the eschar
was covered with gold-beater's skin.
On the next day the eschars were adherent. There was some swelling
from the severity of the bruise; but the child made little complaint.
On the third day, the swelling remained as before and the eschar
adherent. On the fourth, the swelling had nearly disappeared.--The
eschar separated in nine days from the infliction of the wound,
leaving the parts healed and free from scar.
CASE XI.
Mrs. G. was bitten by a little dog on forefinger about a fortnight
ago. There is now a very irritable, inflamed, fungous sore. I removed
the fungous by a pair of scissors and applied the lunar caustic to
form an eschar.
On the succeeding day, I found that the patient had applied a little
lint before the eschar was dry, which had prevented it from remaining
adherent. I reapplied the caustic and desired that the eschar might be
exposed to dry.
The eschar remained adherent, the inflammation subsided and the case
gave no further trouble.
CASE XII.
A servant maid was bitten by a dog in four places--severely on the
forearm--three days ago. Adhesive plaster had been applied. There is a
wound across the arm two inches in length and three-fourths of an inch
in breadth, attended by dull pain, and swelling of the arm. I applied
the caustic to form an eschar, covering it with goldbeater's skin.
On the following day the eschar remained adherent round the edges, but
had a puffy feel in the centre; I pierced it with a penknife and a
little bloody fluid escaped, and I touched the orifice thus made with
the caustic. The swelling remained as before, with a degree of
soreness.
On the next day the swelling had subsided. The eschar had the same
character; a little fluid was again evacuated and the caustic applied
to the orifice as before.
This mode of treatment was pursued for nine successive days when the
eschar remained adherent in every part.
This patient continued her usual avocations all along. Under any other
plan of treatment I think it impossible that she should not have been
compelled to rest for a number of days.
Adherent eschars were formed on the other three bites which were less
severe, from the first application.
A very irritable sore sometimes forms after the application of
leeches. I knew one lady who was confined during five weeks with
several sores on her foot from such a case. I have no doubt that the
application of the caustic would have prevented all the inconvenience
and suffering she experienced. This observation will be confirmed by
the following case.
CASE XIII.
Am old man applied leeches to the instep for inflammation occasioned
by a bruise. Several very irritable sores were produced with some
swelling. I applied the lunar caustic to form an eschar.
On the following day, the eschars were adherent, the swelling had
subsided, and he had slept well for the first time of several nights.
I do not, however, think the lunar caustic would succeed in such cases
if attended by great inflammation, without the previous application of
a cold poultice with rest for a day or two.
II. ON BRUISES.
It has been already observed, p. 9, that the caustic is an invaluable
remedy in cases of bruised wounds of the shin. In these, as in all
other cases, the value of this remedy is greatly enhanced by an early
application. In bruises on the shin I have not had a single instance
in which I was not enabled to effect a cure by the adherent eschar, if
application was made to me early. The difficulty of forming an
adherent eschar is always increased by delay; but in these bruises
along the shin there is an additional reason for this increased
difficulty, arising out of the tendency observed in them, to the
formation of a slough.
In this place I have, indeed, to make an observation of particular
interest, both in a pathological and curative point of view; it is,
that the formation of this slough has always been prevented by an
early application of the caustic, in the cases which have hitherto
fallen under my care. This fact may probably admit of explanation in
the following manner; the bruise partially destroys the organization
of the part, and the subsequent inflammation completing what the
injury had partially effected, a loss of vitality takes place, and
the slough is formed. The early application of the caustic has
already been shown to have the remarkable effect of preventing the
inflammation consequent upon certain wounds, and thus the part is
suffered to recover from the injury done to its organization, and its
vitality is preserved.
Whether this mode of explaining the fact be correct or no, the fact
itself is extremely important, for the formation of a slough, which
the early application of the caustic can alone prevent, renders it
quite impossible to effect the formation of an adherent eschar.
When the patient applies too late after the accident to prevent the
formation of a slough we must still treat the case by the caustic. It
is to be applied over the bruised and inflamed part. The eschar
remains adherent round the part occupied by the slough and prevents or
moderates the inflammation, and when the slough separates an eschar is
to be formed over the exposed sore.
In the neglected and severer cases of bruise attended by much
inflammation, it will be found best to treat the part for a day or two
by a cold poultice to give time for the inflammation to subside;
otherwise the caustic might induce vesication of the skin, as I have
mentioned already, p. 5, and the eschar could not be adherent.
CASE XIV.
The first case of bruise which I shall detail was not severe, but will
serve to illustrate the mode of treatment by the adherent eschar.
Mr. Symons, aged 60, slipped off a chair and bruised the shin, last
evening; the skin was removed to the extent of an inch in one part and
a square inch in another. He applied a common poultice. During the
night he had much pain, and to-day there is much inflammation round
the wounds. I applied the lunar caustic over both wounds and covered
the eschar with gold-beater's skin to prevent the contact of the
stocking.
On the following day the eschar was found to be perfect. The pain had
entirely ceased. There was a little vesication round one of the
wounds. I simply evacuated the fluid of the vesication and left the
part exposed to dry.
On the third day there was no pain or inflammation, and the eschar
remained adherent.
From this time no remedy was required. The eschar separated leaving
the surface healed, in about a month from the occurrence of the
accident. The patient suffered no sort of inconvenience nor was he
confined from his labours a single day.
CASE XV.
The following case was far more severe, but the mode of treatment was
not less efficacious.
Mr. Granger, aged 36, was exposed to a severe bruise by a great weight
of stones which had been piled up, falling upon the outside of the
leg; he was extricated from this situation with much difficulty.
Besides the bruise, the skin was removed from the outside of the leg
to the extent of ten or twelve inches in length, and in some parts an
inch and half in breadth; and in the forepart of the ankle a deep
furrow was made by the rough edge of one of the stones. I applied the
caustic in about half an hour after the accident, over the whole
surface of the wounds, and protected the eschar by the gold-beater's
skin. The patient was directed to keep the leg cool and exposed to the
air. He took no medicine.
On the succeeding day the leg was a little swelled, but the patient
did not complain of any acute pain but only of a sense of stiffness.
An adherent and perfect eschar was found to be formed over the whole
extent of the wound. There was no fever.
On the third day, the swelling had abated. No further remedy. The
patient was still enjoined to rest.
On the fourth day the swelling was nearly gone. The eschar remained
adherent. The patient walks about.
From this time the patient pursued his avocation of a stone-mason; no
further remedy was required; no inconvenience experienced; and the
eschar separated in about a month.
I think it totally impossible to have cured this wound, by any other
remedy, in less than a month; during which period the patient must
have suffered much pain and fever, and have been quite confined.
It is also quite certain, I think, that there would have been an
extensive slough, from the severity of the bruise. This was doubtless
prevented by the application of the caustic.
CASE XVI.
J. Jennings, bricklayer, aged 26, fell through the roof of a house and
bruised and lacerated his shin rather severely to the extent of an
inch and half in one part and in several other places in a less
degree. I applied the lunar caustic to the wound immediately.
On the following day the eschar was found to be adherent, and there
was neither pain nor swelling.
The eschars separated in nine days leaving the wounds healed.
It is remarkable that the eschar remains a greater or less time over
the wound according to the severity and exigency of the case. This
case being less severe than the former one the eschar remained upon
the wound during a much shorter period of time.
CASE XVII.
An old man, aged 60, received a bruise upon the occiput from a fall;
the skin was lacerated and removed to the extent of half-a-crown. I
applied the lunar caustic soon after the accident.
On the next day an adherent eschar was formed. There was neither pain
nor swelling.--The eschar separated in a fortnight.
CASE XVIII.
Mrs. C. aged 40, was detained on a journey by a bruised wound on her
knee, received a fortnight before, which was healing very slowly under
the usual mode of treatment. The inflammation was subsiding but the
sore was extremely irritable and painful, and she was prevented from
moving. From the degree of inflammation still present, I applied the
lunar caustic very slightly over the sore and not over the inflamed
skin; I left the eschar to dry, but was very doubtful, from the same
cause, whether it would be adherent or no.
On the succeeding day I found that the eschar did remain adherent and
that the inflammation was diminished, and the soreness had entirely
subsided after that induced by the caustic had ceased.
On the next day, the lameness was gone, and there was no sort of
inconvenience from the wound. My patient continued her journey on the
following day, so that I do not know when the eschar separated.
In regard to the inflammation attendant on these wounds, I would
remark that slight inflammation is relieved by the application of the
lunar caustic and does not prevent the formation of an adherent
eschar; but very severe inflammation requires the application of the
cold poultice and lotion over the wound, and it is necessary to watch
for the period when an eschar may be attempted with the lunar caustic.
This a little experience will readily teach.
It is further to be particularly observed that the inflammation
attendant on a recent wound is removed by the caustic, when the same
degree of inflammation at a later period, and with suppuration, would
be aggravated and require the cold poultice and lotion, and render
the formation of an adherent eschar impossible. This fact, the result
of much experience, is extremely interesting, and, I think, not easy
to be explained. It is illustrated by the following case.
CASE XIX.
Robert Hill, aged 16, received a blow yesterday from a bone which was
thrown at him, upon the outer condyle of the humerus. He complains of
extreme pain and there are much redness and swelling. I applied the
lunar caustic and directed the part to be exposed to the cold air.
On the succeeding day, I found that the eschar was quite adherent, and
that the pain, redness and swelling had much subsided, although there
was some stiffness of the elbow.
On the third day there was still further amendment. From this time no
remedy or attention was required.
CASE XX.
It frequently occurs to surgeons to receive slight wounds upon the
hands which prove very troublesome. Of this kind is the following.
Mr. L.C. had an irritable and inflamed sore on the ulnar side of the
third finger, occasioned by a bruise a fortnight ago. Many
applications had been made during this fortnight but the sore had no
disposition to heal. I applied the lunar caustic to form an adherent
eschar.
From this time the pain and inflammation subsided. The eschar remained
firm and adherent, and in six days separated leaving the wound
healed.
III. ON ULCERS.
From the preceding observations it would naturally be concluded that
the lunar caustic would afford a remedy for the treatment of ulcers.
This conclusion is perfectly just. Yet there are many circumstances
which render the mode of treating ulcers by the caustic, efficacious
or the contrary.
In order that the treatment by eschar may be successful, there must be
the following conditions in regard to the ulcer: first, the surface
occupied by the ulcer must not be too extensive; secondly, it must
not be exposed to much motion or friction; and thirdly, it must not be
attended by a profuse discharge; for all these circumstances have a
direct effect in, preventing the formation of an adherent eschar or of
removing it if formed.
I observe, therefore, that I have not found the mode of treatment by
eschar to succeed in large ulcers of the legs. But in small ulcers,
and especially in those irritable and painful little ulcers which are
so apt to form about the ankle and occasionally occur near, the tendo
achillis, and in which Mr. Baynton's plan is inadmissible, the caustic
is invaluable; in these cases the cold poultice and lotion should
precede the application of the caustic, for a few days, that the
irritability and inflammation of the sore and surrounding skin may be
first subdued; and after the eschar is formed, the part must be kept
exposed to the air and defended from external injury, by enjoining the
patient to wear trowsers and to be careful not to disturb the eschar.
The plan of curing ulcers is exactly what has been described in the
treatment by the unadherent eschar. For in these cases the eschar is
generally unadherent at first. It is necessary therefore in all cases,
except those of very small ulcers, to examine the eschar, making a
small puncture or rather smooth incision in its centre, so as to
evacuate the subjacent fluid if there be any, taking great care not to
break down or bruise the eschar so as to leave its inferior surface at
all ragged. This operation should be repeated daily until the eschar
proves to be quite adherent. And if the ulcer be rather large, rest
should be enjoined until the adherent eschar be fully and safely
formed, and a dose of saline purgative may be interposed. It must also
be particularly borne in mind, that the eschar must be constantly
defended by the gold-beater's skin, which must be removed and
reapplied at each examination.
I have here spoken of ulcers upon the legs. But the same observations
apply to ulcers on other parts of the body, and these are, in general,
far more manageable than the former, and do not require the same rest
during the unadherent state of the eschar.
CASE XXI.
Mrs. Butcher, aged 52, has two ulcers a little above the outer ankle,
one the size of half-a-crown, the other, of a shilling, of four months
duration, which are now in a healing state by the application of
cerate and poultice; the healing process is going on very slowly.
These ulcers were caused by a fall which bruised the part but made no
wound at the time; two small spots, which she compared to the pustules
of small-pox, formed, broke, and gave rise to the ulcers. I applied
the lunar caustic to form eschars.
At this time I had not begun to defend the eschar by the gold-beater's
skin, and in consequence both these eschars were torn by the patient's
stocking having adhered to them, and there was an oozing of fluid from
the centre of each eschar on examination on the following day. I again
applied the lunar caustic.
On the succeeding day, I found that the large eschar had again been
disturbed, the patient having applied a little linen, instead of
leaving it exposed. I reapplied the lunar caustic.
On the next day both eschars were complete, but there was a little
fluid under the centre of each, which required to be evacuated by an
incision. There was little inflammation or pain.
On the following day, my patient expressed herself as astonished at
the rapid amendment. A little fluid was again evacuated from beneath
the centre of the eschar.
On the next day the smaller eschar was quite adherent; under the large
one, there was still a very little fluid.
About the ninth day, both the eschars were perfectly adherent. In two
days afterwards the eschars began to separate round the edges, and in
a few days more, it was necessary to remove the separating portion by
the scissors.--In the course of time the eschar separated completely,
leaving the ulcers healed.
Mrs. Butcher had no pain after the first four days from the
application of the caustic, and in a week was able to attend to her
household affairs.
CASE XXII.
J. Copeland, blacksmith, aged 38, came to me with many deep
ulcerations, from the size of a horse bean to that of a pea, attended
with great pain, heat, itching and excoriations of the surrounding
skin, obliging him to rest at different times, for several days
together. These ulcers came without any apparent cause, have continued
for many weeks, and have only been a little benefitted by rest,
although he has applied many kinds of ointment, the last consisting of
equal parts of mercurial and of the tar ointment. I applied the lunar
caustic upon each ulcer, but not over the excoriation, and I enjoined
the patient to leave the whole exposed to dry.
On the following day, I was gratified to find that eschars had formed
upon every ulcer; upon examination, a little fluid was found to
subsist under several of the larger eschars; this I evacuated, and I
then applied the lunar caustic to the points from which it had issued
to make up the breach of continuity of the eschars over the surface of
the ulcers. There was far less inflammation and scarcely any pain, and
he has continued his occupation of blacksmith.
On the third day nearly all the eschars were adherent; three, however,
had unfortunately been removed by an accident; I renewed them by again
applying the caustic.
In four days after the last report, most of the eschars had separated
from the smallest ulcers leaving the parts healed.
In a day or two more, my patient took cold and was affected with
hoarseness and cough, and the skin round the eschar became excoriated
a little. I directed a saline purgative and applied the lunar caustic
to the excoriated parts.
On the succeeding day his cold was better and the eschars adherent. I
directed five grains of the Plummer's pill to be taken night and
morning, which he continued about a week.
Five days after this period, I again observed a disposition to
excoriate. I applied the caustic.
In two days more, the eschars were adherent, and there was no further
appearance of excoriation.
In ten more days, the eschars had separated and all the ulcers and
excoriations were completely healed.
This case occurred several years ago, and there has been no return of
the affliction whatever.
CASE XXIII.
Mr. Marshall, aged 60, had a troublesome ulcer under the outer ankle,
of an oblong form and of the size of sixpence. He has been long
subject to ulcers of the legs, and he had a similar ulcer to the
present one in the same situation, some years ago, which proved
extremely difficult to heal under usual remedies. The veins are
varicose.--From the small size of the ulcer, I applied the lunar
caustic and protected the eschar by the gold-beater's skin.
On the following day, I found the eschar complete but unadherent by
the effusion of a little fluid; this I evacuated daily in the manner
already described, for about a fortnight, when the eschar became
adherent.
During the progress of the cure a little excoriation formed round the
eschar. I touched the parts with the caustic, and the eschar thus
formed served to support that formerly made, and so to do good. The
whole adhered until the sore was very nearly healed; but as it was
situated in a part greatly exposed, it was removed by accident. The
caustic was again applied; fluid formed underneath the eschar as
before and required evacuating thrice; but at length the eschar
adhered, and in due time separated leaving the ulcer quite healed.
The same patient has since been affected by similar ulcers at
different times in different parts of the leg. He applied early and
they were each time easily cured by one application of the caustic. He
has also twice had injuries upon the shin, which were readily cured in
the same manner.
CASE XXIV.
The following case must not be regarded as altogether trifling. For
such sores are very apt to spread and to remain long very
troublesome.
An old gentleman came to me with an oblong ulcer on the shin about an
inch in length; it was very painful and inflamed. I applied the lunar
caustic to form an eschar and requested him to call on the following
morning. He did not come, however, but on seeing him the next day it
was requisite to evacuate a little fluid; this was repeated on they
third day, after which period the eschar remained adherent, and the
part totally free from pain.
The eschar separated in about three weeks leaving the part healed.
CASE XXV.
The following case illustrates the superior efficacy of the lunar
caustic over the ordinary modes of treatment in some ulcers of the
legs, and will, I trust, be found particularly interesting.
Mr. G.B. aged 60, a very tall and stout person, had two ulcers, one of
the size of a shilling upon the back of the leg just above the tendo
achillis, the other rather less, on the outside of the leg; they were
caused by his scratching the parts severely three months before; and
he had used various remedies in the interval. There were some oedema
of the leg to which he is subject, and much pain and inflammation of
the ulcers. I directed the application of a cold poultice and lotion,
and prescribed the pil. hydrarg. every second night with an aperient
draught the following morning.
This plan of treatment was continued for a number of days without any
appearance of healing in the ulcers. As the inflammation had subsided
I proposed to adopt the mode of treatment recommended by Mr. Baynton,
fearing that any attempt to heal the ulcers by eschar would fail on
account of the oedema. This project was deferred, however, by the
patient's wish to try the effect of sea-bathing. After a month's
residence on the sea shore I was, on the return of my patient, again
requested to examine these ulcers, which I found very nearly in the
same state as before, only with the addition of some excoriations. I
recommended the cold poultice for a few days to allay inflammation,
and then tried Mr. Baynton's plan, dressing the leg myself daily; on
the fourth day, however, the sore above the tendo achillis became so
irritable that I was compelled to desist and to remove the plaster and
bandage, and I again directed the cold poultice with rest, for a few
days.
When the inflammation had again subsided, I ventured, notwithstanding
the oedema, to apply the lunar caustic to form an eschar, enjoining
rest and the horizontal position.
On the following day complete but unadherent eschars were formed over
each sore. There, had been no pain after the smart of the caustic had
ceased. On carefully making an incision into the centre of each
eschar, a little fluid was evacuated.
On the second day, rather more fluid was evacuated in the same manner.
There was a little more inflammation round the eschar than yesterday.
On the third day the sores were exactly in the same state. On the
fourth, the patient having used his leg a little, rather more fluid
was evacuated from the centre, and there was rather more inflammation
round the edges, of the eschars. I enjoined the strictest rest.
On the fifth day, there were less inflammation and discharge.
From this day until the tenth the fluid required daily evacuation; the
eschar became adherent, and I allowed my patient to walk about.
In about six weeks the eschar was nearly separated and I removed it
by the scissors, leaving only a portion adherent of the size of a
pea. It had been prevented from being removed from the beginning, by
the gold-beater's skin. The smaller eschar had dropped off leaving the
ulcer quite healed. In a week more the last portion of eschar
separated from the larger sore, leaving it also quite well.
CASE XXVI.
The following case occurred in the person of a lady with varicose
veins and far advanced in pregnancy. Its speedy cure by the caustic
was, therefore, the more remarkable, and saved her much trouble and
suffering.
Mrs. C. aged 40, had two small irritable and inflamed ulcers, under
the inner ankle. I applied the lunar caustic to form an eschar.
It was requisite to evacuate a little fluid from under the eschars for
three successive days; they then remained adherent.
About the usual time the eschars separated, leaving a small point of
the size of a pin's head, unhealed; this I again touched with the
caustic. The case required no further attention.
This case leads me to caution my readers always to examine the parts
carefully after the separation of the eschars, and if there be the
slightest ulcer remaining to apply the caustic to it.
CASE XXVII.
Mrs. Wakefield, aged 36, had an extensive ulceration with excoriation
on the upper part of the right breast, of two months continuance; it
had been greatly aggravated by improper treatment. I applied the lunar
caustic over the whole ulcerated and excoriated surface. It gave much
pain.
On the following day I was concerned to find that part of the eschar
had been separated by the patient's dress. I repeated the application
of the caustic and again directed the part to be exposed and carefully
protected from being disturbed. The breast required to be supported
being full of milk.
On the succeeding day an adherent eschar existed over all the
ulcerated parts, and the pain, redness, and irritation had nearly
subsided.
On the fourth day there was still less pain and inflammation. On the
eight the eschars had separated and the breast was quite well.
CASE XXVIII.
Mrs. U. aged 60, has been subject to ulcerated legs for several years.
She has one ulcer on the outer ankle of the size of a shilling, and
another behind it of the size of a horse-bean; they have been
extremely troublesome and under surgical treatment for the last year,
but during the last few weeks she has tried cerate, poultice, and the
cold lotion. The leg is much swollen and inflamed, the redness
extending several inches round the wound and over the instep; the
oedema increases towards night. She has been in the habit of taking
saline purgatives frequently.
I directed my patient to continue the cold poultice and lotion, and to
rest completely for several days. At this period, the inflammation
having somewhat abated, I applied the lunar caustic to form eschars
and protected the parts with gold-beater's skin.
On the following day there was a slight increase of redness round the
eschars. Upon making an incision into their centre some fluid was
evacuated. The same report was made on each of the two following
days.
On the seventh day, the eschars having been neglected, fluid had
escaped from beneath the eschars at their edges, and my patient
complained of more pain. A little more fluid escaped in the same
manner on the following day on making a little pressure upon the
eschars. I applied the caustic to make up the breach.
Subsequently to this day there was an increase of inflammation. From
this circumstance, and from the neglect of the eschars for two or
three days already mentioned, I suspected the formation of a scab
under them. It was impossible to pierce the eschars by the penknife
without breaking them, as they had become too hard and thick by delay
and the addition of the scab.
I again directed the cold poultice for four or five days. On examining
the wounds on the separation of the eschars, I found the healing
process going on. I reapplied the lunar caustic to form eschars, and I
evacuated a little fluid from their centre for three successive days.
At this time the patient took cold and a smart attack of fever came
on, and the part round the eschars became much inflamed. I prescribed
an emetic and purge, and a cold poultice and lotion.
In the space of a week I again attempted to form an eschar over the
larger wound, for the smaller one had quite healed.
The next day I discharged a little fluid from the centre, and again on
the eight or nine succeeding days, giving saline purgatives.
After this time the eschar remained adherent, and no further remedy
was required.
This case is particularly interesting and important, as it illustrates
the plans to be adopted in two circumstances of no unfrequent
occurrence; 1. when there is an attack of fever and increased
inflammation, and 2. when a scab forms underneath the eschar. In both
cases we must relinquish our attempt to form an adherent eschar for a
time,--apply the poultice,--and recur to the caustic in the course of
a few days.
In the beginning of my trials of the treatment of the ulcers by the
caustic, I was repeatedly betrayed by the smooth appearance of the
eschar, to think that all was going on well, when in fact a scab was
all along forming underneath. In these cases inflammation soon
followed, and it was only by carefully and daily evacuating the fluid
effused under the eschar that I at length succeeded in effecting an
adherent eschar free from surrounding inflammation. This remark cannot
be too often repeated.
CASE XXIX.
The peculiarity of the present case arose from neglect in evacuating
the fluid effused under the eschar the day succeeding its formation,
the consequence of which was that the edges of the eschar became
raised all round, without however being entirely detached.
Mr. Draper, aged 50, had a small irritable ulcer of the size of a
horse-bean, upon the shin, of a month's duration, with surrounding
inflammation to the extent of several inches. I applied the lunar
caustic to form an eschar and protected it with gold-beater's skin.
On the following day, it appeared from the flatness of the surface,
that the eschar was adherent; the inflammation remained as before.
On the next day the eschar was raised all round its borders,
presenting the appearance of an elevated ring. I made an opening in
one point of this ring by a penknife and evacuated the fluid, and I
again applied the caustic all round in order to give firmness to the
edges of the eschar.
On the succeeding day an opening was made in the centre of the eschar
and a little more fluid was evacuated.
This mode of treatment was continued daily for about a week, the
inflammation gradually subsiding and the eschar becoming adherent and
corrugated. In about three weeks, the patient thinking the sore quite
well detached the eschar; there was still, however, a minute ulcer
left, which was touched with the caustic.
CASE XXX.
C. Cocking, aged 17, has an ulcer of the size of half-a-crown on the
inner part of the knee, occasioned by an accident. He had been a month
under surgical care in the country when he applied to me, but the
ulcer continued without disposition to heal, and fungous; it had
apparently been treated by a solution of sulphate of copper. I applied
the lunar caustic over the surface of the sore and upon the
surrounding skin.
On the following day, the eschar was unadherent and puffy, and on
piercing it a little fluid escaped. The incision into the eschar was
repeated three or four successive days, but the eschar still retained
its puffy character; I therefore directed a poultice to be applied to
remove it.
In two days the eschar was separated leaving the ulcer with its
fungous appearance. I removed the fungous part by scissors, and
directed the poultice to be applied and to be continued for two days.
I then formed another eschar. This required a daily puncture for the
evacuation of subjacent fluid, for six days; it then remained
adherent, and in about a fortnight it separated leaving the ulcerated
surface healed. This patient was not at all confined.
CASE XXXI.
Mr. S. aged 30, had a sore two inches in length in the groin, the
remains of a phagedenic ulcer. It had remained stationary a whole
fortnight under the ordinary treatment by bandage. I applied the lunar
caustic to form an eschar and then the gold-beater's skin.
The day afterwards, I found the eschar incomplete and I applied the
caustic again. The eschar was still incomplete on the following day,
and the caustic was again required to be applied to the denuded parts.
On examination two days afterwards I found the eschar complete and
adherent.
On the fourth following day, great part of the eschar had separated
leaving the ulcer healed, and I had no occasion to see the patient
again.
IV. OF SOME ANOMALOUS CASES.
1. _Of Whitlow._
The lunar caustic is very useful in the treatment of this painful
affection. Patients seldom apply to the surgeon before suppuration has
taken place. It is then, I think, the best plan to open the abscess
freely, to apply the caustic well within the cavity, and then to
envelope the part by the cold poultice and lotion. In this manner the
pain and irritation are almost immediately removed, after the smart of
the caustic has subsided. A second application is seldom necessary.
In some cases, however, there is an increase of inflammation in a day
or two, which requires the caustic to be again applied. When the
inflammation has subsided, the loose cuticle may be removed, and the
caustic must be applied to form an eschar.
In slight cases the lunar caustic may be passed over the inflamed
part, and in this manner suppuration and the continuance of
inflammation is often prevented.
In those cases in which the suppuration is artificial and attended
with severe diffused inflammation, the pus should be evacuated and a
cold poultice applied for a day or two; for the too early application
of the caustic would only add to this kind of inflammation; see p. 11;
afterwards the skin may be removed, and if there be excoriations the
caustic may be lightly applied.
2. _Of Inflammation of the Finger._
The following case of inflammation of the finger occurred without any
assignable cause.
CASE XXXI.
A young man, aged 18, came to me with a painful swelling of the
middle finger of the right hand; suspecting deep-seated abscess, I
made a free incision and evacuated a little pus. I then applied the
lunar caustic within the cavity and directed a cold poultice to be
applied with lotion.
On the fourth day my patient had returned to his occupation as a dyer.
CASE XXXII.
Miss B. aged 23, had a slight scratch on the inside of the index
finger, which issued in severe inflammation extending over the back of
the hand. I made a free incision in the part first affected, evacuated
a little pus, and directed a poultice to be applied.
On the following day, there was less pain but still great swelling at
the back of the hand, which, I think, would have been removed had the
caustic been used.
I now applied the caustic freely within the orifice.
On the following day there was less swelling and discharge.
Two days afterwards, the caustic was again applied, and in eight days
from the first application of the caustic the hand was quite well.
3. _Of Fungous Ulcer of the Navel in Infants._
It sometimes occurs that a little fungous sore exists upon the navel
in infants which is difficult of cure in the ordinary way. I had one
case which had subsisted for two years, and another, which had
continued for two months, and were, during those periods, a source of
great trouble and uneasiness to the mothers of the little patients.
These ulcers are easily cured in the following manner.
The fungus is to be completely removed by a pair of scissors, and when
the bleeding has quite ceased, the lunar caustic is to be applied,
and the part defended by the gold-beater's skin and kept carefully
from any moisture.
In one of the cases mentioned above the eschar was accidentally
separated twice and required to be renewed; but both cases were cured
in the space of a few days.
4. _Of Inflammation of the Knee._
Servant women, I suspect from much kneeling in scouring stairs, &c.
are subject to a species of inflammation of the knee which is
frequently extremely troublesome.
In one case suppuration of the integuments took place in the forepart
of the knee, and the patient was obliged to leave her situation and go
to her friends at a distance, although every antiphlogistic means was
tried for her relief.
In two other cases, after the application of twenty leeches and the
administration of an emetic and purgative medicine, I applied the
lunar caustic freely over the whole surface of the knee previously
moistened with water. In a few hours the cuticle was raised and
vesicated; I evacuated a viscid puriform fluid, and I directed the
constant application of the cold poultice and lotion.
In a few days all inflammation subsided and the patients remained
well.
These three cases having occurred to me at the same time, and being
apparently equally severe, I was enabled to judge of the efficacy of
this use of the caustic, and I can strongly recommend it to a future
and further trial. Its application causes more pain than a blister,
but not so much as to form an obstacle to its employment.
It may not be unimportant, here, to suggest the trial of the caustic
in other cases of inflammation, in which a more than usually active
local remedy is required.
5. _Of Tinea Capitis, &c._
In this place I have only to observe that I have in some cases
completely succeeded, in others completely failed, in the cure of
tinea capitis, by the lunar caustic. As I have not hitherto
distinguished these cases from each other; and as I could only offer
conjectures on the subject, I think it best to leave it for future
inquiry.
The same observation applies to some other cutaneous affections which
I need not specify more particularly at the present.