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, presentingthe 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 welldetached the eschar; there was still, however, a minute ulcer left, which was touched with the caustic.
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.
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 thecaustic 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.
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 isseldom 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 withsevere 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.
A young man, aged 18, came to me with a painful swelling of the middlefinger 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.
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 lunarcaustic 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.
It is by no means my intention to recommend the application of the lunar caustic as an infallible remedy for all local diseases. I am quite aware of the propensity, in recommending a favourite remedy, to extend its use beyond its true limits. The caustic, like all other remedies, requires to be employed with discrimination; and it is therefore my object in this little work, to state in which cases it is, and inwhich cases it is not, useful and successful.
With this object, I have thought it not improper to add, in a concluding chapter, some observations on those cases in which I have found the lunar caustic to be inadmissible. It will, at the same time, be found that such cases, in the course of their treatment by the ordinary measures, not unfrequently become fit cases for the application of the caustic, with the view of more speedily completing the cure.
This observation is particularly applicable to the cases of burns, of large ulcers, of fungous ulcers, &c.
The caustic is inapplicable in extensive lacerations, for the same reason that it is so in extensive ulcers.
I have found the caustic of little use in incised wounds, and should not employ it except in such wounds received in dissection.
I have failed in my attempts to heal scrofulous sores by the adherent eschar; I would propose the trial with the lunar caustic and poultice.
In erysipelatous inflammation, where vesicles are formed, the caustic does injury, as in recent burns.
I have always found that the caustic has done injury in boils, aggravating rather than diminishing the affection.
1.Of Burns.
The application of the lunar caustic in recent burns or scalds, has always appeared to me to increase the inflammation and vesication, even inducing blisters where there were none before. The caustic must not, therefore, be applied in these cases, until the inflammation has entirely subsided; but when there remains only a small superficial ulceration, the caustic may be passed lightly over the ulceratedsurface to form an eschar which is to be defended by the gold-beater's skin; for the affection is then reduced to the state of a common superficial ulcer. An adherent eschar is generally readily formed, and no further application is required. If the ulceration be more extensive and deeper, the lunar caustic may be applied, and the eschar treated, exactly as in common ulcers.
It may be well to illustrate these points, by the following cases.
A little girl, aged 10, scalded her breast a week ago and has treated itwith the ordinary remedies. There remained a superficial ulceration of the size of half-a-crown. I applied the lunar caustic lightly over the surface of the sore, and then the gold-beater's skin.
On the following day, an adherent eschar had formed, and in five days more it dropped off leaving the ulcer quite healed.
Mr. C. aged 51, scalded his leg ten days ago on the instep. He applied ointments and poultices. The surface remained ulcerated to the extent ofthree inches in length and an inch and a half in breadth, and presented a considerable thick slough in the centre; the inflammation continued to be considerable with some œdema towards the toes. In such a case I should now recommend a cold poultice to be applied for several days; but the present case occurring early in my trials of the caustic, the latter remedy was applied forthwith over both the ulcer and slough.
On the following day I learnt that the pain after the application of the caustic had been considerable for two hours. It then ceased and the eschar became complete; and there was ratherless inflammation and swelling. The patient had kept in bed. I prescribed a pill with the hydrarg. submurias, to be followed by an aperient draught.
On the succeeding day my patient went down stairs and disturbed the eschar, and experienced more pain. The inflammation and swelling were still less. I applied the caustic to the parts of the ulcer exposed by the injury done to the eschar.
During the two following days the inflammation subsided entirely; I evacuated a little fluid from beneath the eschar.
On the next day the eschar appeared adherent, except in the centre which was occupied by the slough.
On the succeeding day, I evacuated a little fluid from beneath the slough.
On the next day I removed the slough entirely by means of a pair of scissors. The subjacent ulcer had a healthy granulated appearance. I applied the lunar caustic to it to form an eschar.
From this time it was necessary to evacuate a little fluid from under the eschar for ten successive days. It thenbecame adherent, and in about a fortnight it separated, leaving the ulcer healed.
The following case will present a specimen of my trials of the lunar caustic in larger ulcers.
Anthony Knowles, aged 44, was kicked by a horse on the leg, above the inner ankle, two years ago. The part has never healed, but still remains in the state of an open ulcer, attended by some inflammation. When I first saw this ulcer it was about two inches indiameter and nearly circular, with high edges, a surface of a greenish colour, and without any healthy granulations. I applied the lunar caustic to form an eschar.
The pain from the caustic was severe for several hours. An eschar had formed round the edges, but in the middle part it was quite wanting; the inflammation surrounding the ulcer had abated, and the green hue of its surface had disappeared. I reapplied the caustic in the central part.
On the following day the eschar appeared tolerably complete in the centrebut had separated at one part of the circumference. I again applied the caustic to the defective part.
On the following day the eschar was defective in several parts, but the inflammation was quite removed, there was no pain, and there had been less smarting after each successive application of the caustic. I again applied the caustic.
On the succeeding day, I learnt that my patient had been intoxicated, and I found the ulcer attended by inflammation. The eschar was by no means complete; some part of it was in adetached state. I removed the loose portions and repeated the application of the caustic.
This sort of treatment was continued for a fortnight without my being able to effect the formation of a complete eschar. I therefore relinquished the idea of healing the ulcer by the adherent eschar; I eventually succeeded in doing so by applying the caustic every third day and the poultice continually, and I had hopes that the cure might be permanent, but he made application to me in two years afterwards with a similar ulcer on the same part.
In another similar case, I removed the elevated hard edges of the ulcer by the lancet, and then tried the caustic, without better success.
The last case I have to give is one of great interest, as it clearly shows the influence of the lunar caustic in subduing the inflammation surrounding ulcerations, and in promoting the healing process, even in cases of phagedenic ulcer. In such cases its influence eminently deserves a still further trial.
Mrs. H. aged 56, has had very extensive phagedenic ulcerations on thelegs and thighs during three years, which began in little red spots and then spread rapidly, destroying the integuments. One of these ulcers, on the thigh, was twelve inches in length and five in breadth, and exhibited the appearance of a deep corroding furrow; it was surrounded by a fiery redness and was attended by extreme pain. There were many other ulcers of the same kind, several nearly of the same magnitude; and the poor patient was compelled to take large doses of laudanum several times in the day. She had formerly been treated for syphilis, and had afterwards taken the sarsaparilla freely; amongst a great variety of localapplications, the white bread poultice had afforded most relief.
I applied the lunar caustic to two of the smaller ulcers.
On the following day the eschars were complete. I applied the caustic to the large sore above described to the extent of three inches square, avoiding its application on the inflamed skin.
On the next day I found the eschar last made complete, and I passed the caustic over the ulcer to the extent of three inches more.
On the succeeding day, the eschar was complete, adherent at those edges which adjoined the cuticle, and floating at the other edges over the ulcer, and in the latter part allowing the escape of matter; round the adherent edges of the eschar the inflammation had entirely disappeared, while it remained fiery as before round every other part of the ulcer.
I continued my trials with the caustic in this case, but it gave so much pain, and I had so little hope of final success, that I altogether relinquished the attempt to treat these ulcers by eschar. Some of the small ulcerswere healed, however, and the larger one assumed a more healthy character wherever the caustic had been applied. It may, therefore, remain a question whether the lunar caustic may not still prove useful in phagedenic ulcers of a smaller size.
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