BY GEORGE W. CALLENDER,| _Assistant-Surgeon to St. Bartholomew’s
Hospital_.
Attention is at present attracted to various applications having for
their object the better healing of wounds and sores of different kinds;
but I should be sorry if, in the search after new, one at least of the
ancient remedies should fall into disfavour. It has been asserted that
poultices are often used to conceal defects of treatment, a kind of
refuge in ignorance of any more advantageous applications, and that they
often do positive harm by inciting profuse, and consequently exhausting,
suppuration, and, no doubt, it is true they favour the tendency to
suppuration which may exist in particular instances, and that they will
increase a suppurating discharge when the latter is already established.
Most remarkable results, however, follow the use of poultices in certain
cases—of lupus, for example. A woman attends at my out-patient room with
ordinary lupus which, when first seen, had eaten away the middle portion
of the upper lip, and had encroached upon the septum of the nose. A
bread poultice was applied day and night to the ulcerated surface, and
she took iodide of potassium. The sore was soon and completely healed.
After six months she returned with the disease worse than ever, but it
quickly healed again under treatment, and would, I am sure, remain well
if she were ordinarily watchful over it. As the iodide of potassium may
have had some influence in this instance, its use was dispensed with in
other cases. A woman was taken into Sitwell ward with extensive lupus of
the nose. It was with difficulty we persuaded her to submit to such
simple treatment as the application of bread poultices continuously to
the sore; she craved for physic, which was denied her. Very quickly the
sore healed, and she left well. It is needless to record other and
similar cases which have been treated in this simple fashion with the
same satisfactory results.
Some months ago a man was sent to me from Woolwich with an ulcer on the
outer angle of the orbit extending to the conjunctival surfaces of the
lids; it was irregularly scabbed over. In my opinion, and in this I was
confirmed by several of my colleagues, it was an example of so-called
epithelial disease; at all events it had been an open and increasing
sore for nearly five years, and before proceeding to remove it I agreed
to try the effect of some local caustic. To clean the surface a bread
poultice was applied, and it mended so much that this application was
continued, when great part of the sore healed rapidly, and the remainder
cicatrized after being touched with caustic zinc.
All surgeons are familiar with the good results which follow the
application of a poultice to an acutely inflamed surface-part. Quite
recently a woman has been under my care with inflammation of the tissues
about the internal saphenous vein. She has progressed quite well towards
convalescence by keeping the limb at rest, and by having the inflamed
vein-track covered with a large poultice of linseed meal; no other
treatment has been required. It is a common fault, not so much perhaps
in hospital as in private practice, not to give a poultice the chance of
curing a local inflammation by limiting its application to the part
affected. A poultice to be of any use should widely cover the tissues
which surround the seat of inflammation; for example, if the hand is
inflamed the poultice should not only completely envelope it, but should
extend at least half-way up the fore-arm: and this rule holds good
especially when poultices are used for superficial or for subcutaneous
diffused inflammation.
A little girl I saw recently in Sitwell ward had a fierce attack of
inflammation, after measles, which involved one side of her face and
neck. As it threatened to lead to suppuration we made three punctures,
carried deeply amongst the tissues, and then applied a succession of
large poultices to the entire of the affected side. In twenty-four hours
the child, from a condition of great depression, was well enough to
leave the hospital—the swelling was much reduced, probably by the
draining away of serous fluid, but no suppuration was established. I
often direct a bubo to be punctured with a grooved needle, the needle
being carried across so as to make a double opening; poultices are then
applied, and if the parts are moderately rested, the swelling will
usually subside; if the bubo is suppurating the same treatment will
suffice to evacuate the pus, and this having discharged the bubo
disappears, and no trace even remains of the openings through which the
pus has passed out. In cases such as those referred to, some without,
some with a surface lesion, the mischief is remedied without any
suppurative action being set up by the use of the poultices.
It is desirable, when there is much discharge into a poultice, to dust
over the skin about the openings whence the discharge issues some oxide
of zinc, or some other drying powder; if this precaution is not taken
the matter will irritate and probably enlarge the opening, or will
produce vesicles, which break and leave excoriations, or painful papulæ
on the adjacent integument. It should be remembered also that great heat
is not needed with the poultice; it should be comfortably warm to the
patient, and should never be allowed to get, by comparison with its
condition when applied, so cold as to lessen the temperature of the
part.
Ulcers of many kinds will heal rapidly when treated with poultices; and
when I use the word “rapidly,” I refer to comparative quickness of
healing, as ascertained by measuring the chief diameters of the
ulcerated surfaces; their progressive over-closing is thus very
accurately checked from week to week. This refers more especially to
ordinary ulcers, such as result from injuries. A boy now attends in my
out-patient room who under this treatment is healing up a sore on the
fore-arm, the remains of a bad crushing of the part. Sometimes this
healing is hastened by dusting the ulcer twice daily with powder of
oxide of zinc before the poultice is at such times applied. In Sitwell
ward a woman is just well of a severe phagedænic sore involving the skin
over and below the knee. Mr. Cumberbatch, the dresser of the case, kept
the parts at rest by swinging the limb, and applied at first an ordinary
linseed poultice, then warm water dressing (another form of poultice),
and, to expedite the healing of a few remaining sores, some resin
ointment. The cure has occupied twenty-six days, a very rapid progress
considering the constitutional nature of the affection: no medicine was
needed.
I never could understand, seeing it is desirable to keep the parts
immediately after an operation warm and quiet, why those objects should
not be attained by the use of poultices; nothing I know of is more
efficient to lessen the trouble caused by the starting of a limb after
amputation, than the weight of and the resistance offered by a large
poultice surrounding the stump. But their employment is in disfavour,
first from the fear of their provoking recurrent bleeding, although this
reckons for little if due care has been taken to have the wound
thoroughly dry before closing it, and unless this care is taken there is
little chance of its uniting by the first intention; secondly, by the
prevailing notion that such union is prevented by the relaxing influence
of this kind of dressing. Wishing to put this to the test of experience,
the following cases, amongst others, were placed under treatment.
Having occasion to remove the larger portion of the left upper jaw of a
female, about forty years of age, I brought together the incised wound
of the face with wire sutures, and directed a bread poultice to be at
once applied and renewed at intervals. The entire wound united by the
first intention. A boy had his hand and fore-arm crushed by machinery,
and it was necessary to perform amputation below the elbow. The flaps of
integument were carefully adjusted, and the stump was poulticed. On the
ulnar side the tissues united without suppuration; on the radial a
portion of skin sloughed in consequence of the hurt it had sustained at
the time of the accident, and on this side consequently the repair was
less quickly completed. I recently amputated at the thigh, on account of
strumous disease of the left knee of a boy, and brought the flap
surfaces into apposition. The wound was at once covered with a linseed
meal poultice. The next day, the stump being swollen, the wire sutures
were cut. Bread poultices, and then warm water dressings, were
afterwards employed, and the wound healed without any suppuration having
been set up by the action of the local remedies. What pus did form was
no more than might have been expected from incomplete primary union of
portions of the cut surfaces.
I should like to see a more extended trial given to applications which
keep a wound warm and moist continuously from the time of the operation.
I think their use would give satisfactory results. No doubt they are
most serviceable remedies throughout various forms of ulceration, and
especially so in cases of lupus.
THE HYPODERMIC INJECTION OF MORPHIA IN MENTAL DISEASE: A CLINICAL
NOTE.[7]