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 thefinger, 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.
James Joynes, aged 12, was bitten by an ass, on each side of the middlefinger; 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.
Mr. Worth's daughter, aged six, was thrown down by a dog and bittenseverely 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 escharadherent. 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.
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 lintbefore 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.
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 againevacuated 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.
Am old man applied leeches to the instep for inflammation occasioned by a bruise. Several very irritable sores were produced with some swelling. Iapplied 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.
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 theslough 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 mightinduce vesication of the skin, as I have mentioned already,p. 5,and the eschar could not be adherent.
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 muchpain, 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.
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, fallingupon 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; nofurther 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.
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.
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 painnor swelling.—The eschar separated in a fortnight.
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 wasvery 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 wouldremark 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 andrequire 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.
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 causticand 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.
It frequently occurs to surgeons to receive slight wounds upon the handswhich 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.
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 ofvery 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.
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.
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 appliedthe 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.
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 underneaththe 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.
The following case must not be regarded as altogether trifling. For suchsores 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.
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 theinterval. There were some œdema 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 œdema. 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 œdema, 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 bythe 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.
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.
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 theeight the eschars had separated and the breast was quite well.
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 œdema 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 thepenknife 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 emeticand 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 ascab 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.