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+The Project Gutenberg EBook of An Essay on the Application of the Lunar
+Caustic in the Cure of Certain Wounds and Ulcers, by John  Higginbottom
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: An Essay on the Application of the Lunar Caustic in the Cure of Certain Wounds and Ulcers
+
+Author: John  Higginbottom
+
+Release Date: December 4, 2007 [EBook #23729]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK LUNAR CAUSTIC  ***
+
+
+
+
+Produced by Bryan Ness, Jeannie Howse and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+
+       *       *       *       *       *
+
+    +--------------------------------------------------------+
+    |   Transcriber's Note:                                  |
+    |                                                        |
+    |   Inconsistent hyphenation and archaic spelling in     |
+    |   the original document has been preserved.            |
+    |                                                        |
+    |   Obvious typographical errors have been corrected.    |
+    |   For a complete list, please see the end of this      |
+    |   document.                                            |
+    |                                                        |
+    +--------------------------------------------------------+
+
+       *       *       *       *       *
+
+
+
+ON THE
+
+LUNAR CAUSTIC.
+
+
+
+
+AN
+ESSAY
+ON THE
+APPLICATION
+OF
+THE LUNAR CAUSTIC,
+IN THE
+_CURE OF CERTAIN_
+WOUNDS AND ULCERS.
+
+BY
+JOHN HIGGINBOTTOM,
+_NOTTINGHAM_,
+MEMBER OF THE ROYAL COLLEGE OF SURGEONS
+OF LONDON.
+
+LONDON:
+PRINTED FOR
+LONGMAN, REES, ORME, BROWN, AND GREEN,
+_PATER-NOSTER ROW_.
+1826.
+
+
+
+
+T. WHEELHOUSE, PRINTER, NOTTINGHAM.
+
+
+
+
+TO
+MY BROTHER-IN-LAW,
+
+MARSHALL HALL, M.D. F.R.S.E.
+
+&c. &c.
+THIS LITTLE WORK IS INSCRIBED
+WITH
+GREAT AFFECTION.
+
+_Nottingham, Jan. 6, 1826._
+
+
+
+
+PREFACE.
+
+
+The following pages are presented to the medical public with very
+humble pretensions. It is chiefly with the minor accidents or diseases
+that they have to do; but I shall not consider that I have laboured in
+vain, if I am enabled to mitigate even these little evils of human
+life.
+
+In these prefatory observations, however, I would suggest the question
+whether the caustic may not be employed with benefit even in some of
+the severer diseases to which the human frame is liable. Indeed I
+consider the investigation as only just begun, and many other uses of
+the lunar caustic, besides those detailed in the following pages, have
+suggested themselves to me.
+
+May not the caustic, for instance, be of greater efficacy, because of
+greater power and of quicker operation, than ordinary blisters, in
+some internal diseases?
+
+It is repeatedly stated hereafter, that the application of the lunar
+caustic is a means, in certain circumstances, of subduing external
+inflammation. Might it not, on this principle, be of service in the
+treatment of some of the internal phlegmasiĉ?
+
+It may be observed, that the lunar caustic may be regarded, almost
+without further trial, as an effectual preventive of those cases of
+irritative fever which arise from local injuries, and probably of the
+effects of poisoned wounds in general. I would not, however, in the
+latter cases, fail to render "sure doubly sure" by free excision.
+
+Might not an adherent eschar be easily formed in those cases of
+compound fracture in which the external wound is of moderate size, so
+as effectually to exclude the external air and prevent cutaneous
+inflammation, and in more respects than one, to reduce the case to the
+state of a simple fracture? This object, if attained, would be
+important indeed, and I hope the suggestion will be submitted to the
+most assiduous and cautious trial.
+
+I can have no doubt that the use of the lunar caustic admits of being
+still further extended; and, as I intend to pursue the inquiry, I hope
+at some future period to publish something more worthy of the
+attention of the medical public. In the mean time, the plans hereafter
+suggested must not be adopted without that degree of care, attention,
+and perseverance, which are obviously necessary to render them
+successful.
+
+
+
+
+CONTENTS.
+
+
+CHAPTER I.
+                                                             PAGE
+ON HEALING BY ESCHAR                                            1
+
+  I. _Of the Adherent Eschar_                                   3
+ II. _Of the Unadherent Eschar_                                14
+III. _On the Treatment by Eschar and Poultice_                 21
+
+
+CHAPTER II.
+
+OF THE APPLICATION OF THESE MODES OF TREATMENT TO
+DIFFERENT CASES                                                24
+
+  I. _Of Punctures, Bites, &c_                                 24
+ II. _Of Bruised Wounds_                                       64
+III. _Of Ulcers_                                               82
+ IV. _Of some Anomalous cases_                                120
+
+
+CHAPTER III.
+
+OF SOME CASES IN WHICH THE CAUSTIC IS INAPPLICABLE            130
+
+
+
+
+CHAPTER I.
+
+ON HEALING BY ESCHAR.
+
+
+Having been led, by several circumstances, to try the effects of the
+Lunar Caustic in the treatment of Wounds and Ulcers, and having great
+reason, from these trials, to think that this remedy may be used with
+much advantage far more extensively than has hitherto been done, I lay
+the results of my experience before my medical brethren.
+
+A very natural mode of healing certain wounds and ulcers, is by
+scabbing; but this mode of treatment is attended by many
+disadvantages, as will be pointed out shortly; yet it may be supposed
+to have suggested to me some of those trials of the treatment by
+eschar, which I am about to detail.
+
+
+I. ON THE ADHERENT ESCHAR.
+
+It appears scarcely necessary to describe the immediate and well known
+effects of the application of the lunar caustic to the surface of a
+wound or ulcer. It may, however, be shortly observed that the contact
+of the caustic induces, at first, a white film or eschar which, when
+exposed to the air, assumes in a few hours a darker colour, and at a
+later period, becomes black; as the eschar undergoes these changes of
+colour it gradually becomes harder and resembles a bit of sticking
+plaster; in the course of a few days, according to the size and state
+of the wound, the eschar becomes corrugated and begins to separate at
+its edges, and at length peels off altogether, leaving the surface of
+the sore underneath, in a healed state.
+
+In the formation of this eschar several things require particular
+attention. The application of the caustic should be made over the
+whole surface of the sore; and indeed no part requires so much
+attention as the edges; to make a firmer eschar the caustic should
+even be applied beyond the edge of the wound, upon the surrounding
+skin, for the eschar in drying is apt to contract a little, and in
+this manner may leave a space between its edges and that of the
+adjacent healthy skin.
+
+At the same time, much attention must be paid to the degree in which
+the caustic is applied. In cases of recent wounds unattended by
+inflammation, it may be applied freely; but when inflammation has come
+on, too severe an application of the caustic induces vesication of the
+surrounding skin, and the edges of the eschar may in this manner also
+be loosened and removed. If every part is touched, a slight
+application of the caustic is generally sufficient.
+
+The importance of avoiding all causes which might detach the edges of
+the eschar will be apprehended by the following interesting
+observation, which I have been enabled to deduce from very extensive
+trials of the caustic; it is, that, in every instance in which the
+eschar remains adherent from the first application, the wound or ulcer
+over which it is formed, invariably heals.
+
+Not only the cause just mentioned, but every other by which the eschar
+might be disturbed, must, therefore, be carefully avoided; and
+especially, as the eschar begins to separate from the healed edges of
+the sore, it should be carefully removed by a pair of scissors.
+
+To the surface of the wound the eschar supplies a complete protection
+and defence, and allows the healing process to go on underneath
+uninterruptedly and undisturbed. It renders all applications, such as
+plasters, totally unnecessary, as well as the repeated dressings to
+which recourse is usually had in such cases; and it at once removes
+the soreness necessarily attendant on an ulcerated surface being
+exposed to the open air. In many cases too, in which the patients are
+usually rendered incapable of following their wonted avocations, this
+mode of treatment saves them from an inconvenience, which is, to some,
+of no trifling nature.
+
+It has already been stated how important it is that the eschar should
+be preserved adherent. To secure this still more effectually, I have
+found it of great utility to protect it by a portion of gold-beater's
+skin. The skin surrounding the wound is simply moistened with a drop
+of water, and the gold-beater's skin is then to be applied over it and
+over the eschar, to which it soon adheres firmly, but from which it
+may be removed at any time, by again moistening it for a moment with
+water; the same bit of gold-beater's skin admits of being again and
+again reapplied in the same manner.
+
+The other circumstances which render the eschar unadherent will be
+mentioned hereafter. In the mean time the fact stated p. 6, will
+sufficiently establish the propriety of treating distinctly of the
+adherent eschar.
+
+I now proceed to mention some other effects of the application of the
+caustic. The first is that, in cases in which there would be much and
+long continued irritability and pain, as in superficial wounds along
+the shin, all this suffering, and its consequences in disabling the
+patient, are completely avoided. A blush of inflammation forms around
+the eschar, but this gradually subsides without any disagreeable
+consequences, and the inflammation which would otherwise have been set
+up is entirely prevented by the due formation of the eschar.
+
+If inflammation be previously established, it is increased, at first,
+by the application of the caustic. But if this inflammation be not
+severe, and if the eschar remain adherent, all inflammation, both that
+induced by the application of the caustic, and that existing
+previously, entirely subsides. When the previous inflammation round
+the ulcer is considerable, however, the application of the caustic
+would induce vesication, and it should in such a case of course be
+avoided, and another mode of treatment to be described hereafter must
+be adopted.
+
+I would introduce in this place some observations on the comparative
+effects of healing by eschar and by scabbing. On the subject of
+scabbing I must refer my reader to the well known work of Mr. John
+Hunter. The advantage of healing by eschar over that by scabbing is
+quite decided. By comparative trials, I have found that whilst the
+scab is irritable and painful, and surrounded by a ring of
+inflammation, the adherent eschar is totally free from pain and
+inflammation; and that whilst the scab remains attended by
+inflammation and unhealed, the eschar is gradually separating, leaving
+the surface underneath completely healed. To these observations I may
+add that the success of the plan of healing by eschar is infinitely
+more certain as well as more speedy than that by scabbing.
+
+I shall, in conclusion, briefly recapitulate the advantages of this
+mode of treatment. In the first place, it will be found far more
+efficacious and speedy than any other; secondly, it has the great
+advantage of saving the patient much suffering and inconvenience; and
+thirdly, it renders the repeated application of dressings and
+ointments quite unnecessary. Its utility is extremely great,
+therefore, where the time of the poor, the expense of an
+establishment, and the labours of the medical officer, as well as the
+sufferings of the patient, require to be considered; and it will I
+imagine be found of no little advantage, in all these respects, in
+many cases which are incident to the soldier and sailor.
+
+
+II. ON THE UNADHERENT ESCHAR.
+
+The eschar is generally adherent in cases of recent injuries, and in
+small ulcers, when they are nearly even with the skin and attended by
+little inflammation. In other cases the eschar is too apt to be
+unadherent, and this arises from the formation of pus or of a scab
+underneath.
+
+If the eschar be unadherent by subjacent pus, it may be ascertained in
+the space of from twelve to twenty-four hours; the centre is generally
+observed to be raised and to yield to the pressure of a probe;
+sometimes the subjacent fluid has partly escaped by an opening at the
+side of the eschar.
+
+When a scab forms underneath the eschar, which does not happen except
+the fluid has been allowed to remain too long under the eschar without
+being evacuated, there are pain and some inflammation, the eschar does
+not separate, but remains long over the sore, and there is no
+appearance of healing.
+
+When it is ascertained that there is fluid underneath the eschar, a
+slight puncture is to be made by the point of a penknife, the fluid is
+to be gently pressed out, and the caustic is then to be applied to
+the orifice thus made. The same plan is to be adopted if the fluid
+ooze out at the edge of the eschar; it is to be fully evacuated by
+pressure, and the orifice is to be touched with the caustic. The
+healing process goes on best however when the orifice is in the centre
+of the eschar. After this treatment the eschar occasionally remains
+adherent, but more frequently the fluid requires to be evacuated
+repeatedly, and this should be done every twelve hours, or once a day,
+according to the quantity of fluid formed, taking care that the eschar
+be not needlessly separated by allowing the fluid to accumulate
+underneath. If, from accident, the eschar is separated before the sore
+be healed I would reapply the caustic. At length the eschar becomes
+adherent, and in due time begins to peel off, leaving the surface
+healed.
+
+In every case in which the eschar does not separate favourably, I
+begin to suspect the formation of a scab underneath, in which case the
+whole must be removed by the application of a cold poultice for two or
+three days; this has not only the effect of removing the eschar but of
+allaying any inflammation or irritation; afterwards the caustic must
+be reapplied as before.
+
+The gold-beater's skin is more useful as a protection to the
+unadherent than to the adherent eschar, as the former would be more
+liable to be torn off by accident than the latter. The gold-beater's
+skin must be removed in the manner already described, whenever the
+subjacent fluid is to be evacuated, and must be reapplied after
+touching the orifice with caustic.
+
+The pain experienced on the application of the caustic is greater or
+less according to the sensibility and size of the wound. In small
+wounds it is trifling, and of short duration; it is more severe in
+recent wounds than in ulcers; it soon subsides in every case, and
+then the patient enjoys greater ease than would be experienced under
+any other mode of treatment. Little or no pain is caused on applying
+the caustic after evacuating the subjacent fluid of an unadherent
+eschar. Altogether the pain inflicted by the caustic is far less than
+is generally imagined, and forms scarcely an obstacle to its
+employment.
+
+It may be proper, in this place, to notice such circumstances as
+render the employment of the caustic improper or inefficient. It is
+improper to employ the caustic when the ulcer is too large to admit of
+the formation of a complete eschar; or when it is so situated as to
+render it impossible that the eschar should remain undisturbed, as
+between the toes, unless, indeed, the patient be confined to his
+bed;--or in cases attended by much inflammation, or by much oedema.
+
+I have found no kind of caustic so manageable as the lunar caustic;
+and this is best applied in the solid form. I have thought too, that
+the newly prepared lunar caustic is more apt to dissolve on being
+applied than that which has been longer made and more exposed to the
+air; the latter is therefore to be preferred.
+
+
+III. ON THE TREATMENT BY ESCHAR AND POULTICE.
+
+In many cases in which it is impossible to adopt either the mode of
+treatment by the adherent or the unadherent eschar, it is of great
+utility to apply the caustic first and then a cold poultice made
+without lard or oil: this plan is particularly useful in cases of
+punctured wounds attended by much pain and swelling, and in cases of
+recently opened abscesses. By this application the pain and swelling
+are much subdued and a free issue is secured for the secreted fluid;
+and in no case have I seen the original inflammation increased by it.
+
+It is generally necessary to repeat the application of the caustic
+every second or third day, or every day if the inflammation and
+swelling of the part be considerable, and the cold poultice may be
+renewed about every eight hours. At length, however, the inflammation
+having subsided, the attempt may be made to form an adherent eschar.
+
+I have seen many cases, in which, by this mode of treatment, much
+suffering and perhaps the loss of some of the smaller joints have been
+prevented, particularly cases of deep seated inflammation of the
+fingers, which, having been neglected, have issued in severe
+inflammation, abscess, and terrible fungous growths. In these cases it
+is not only necessary to apply the caustic to the surface of the sore,
+but in every cavity or orifice which may be formed by the disease.
+
+
+
+
+CHAPTER II.
+
+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.
+
+
+
+
+CHAPTER III.
+
+OF SOME CASES IN WHICH THE CAUSTIC IS INAPPLICABLE.
+
+
+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 in which 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 ulcerated
+surface 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.
+
+
+CASE XXXIII.
+
+A little girl, aged 10, scalded her breast a week ago and has treated
+it with 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.
+
+
+CASE XXXIV.
+
+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
+of three 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 oedema 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 rather less 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 then became adherent, and in
+about a fortnight it separated, leaving the ulcer healed.
+
+
+CASE XXXV.
+
+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 in diameter 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
+centre but 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 a detached 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.
+
+
+CASE XXXVI.
+
+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 the
+legs 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 local applications, 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 ulcers were 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.
+
+
+
+FINIS.
+
+
+
+
+T. Wheelhouse, Printer,
+Nottingham.
+
+       *       *       *       *       *
+
+    +--------------------------------------------------------+
+    | Typographical errors corrected in text:                |
+    |                                                        |
+    | Page  41: cautic replaced with caustic                 |
+    | Page  65: eurative replaced with curative              |
+    | Page 107: smuch replaced with much                     |
+    | Page 120: ANOMOLOUS replaced with ANOMALOUS            |
+    |                                                        |
+    +--------------------------------------------------------+
+
+
+
+
+
+End of the Project Gutenberg EBook of An Essay on the Application of the
+Lunar Caustic in the Cure of Certain Wounds and Ulcers, by John  Higginbottom
+
+*** END OF THIS PROJECT GUTENBERG EBOOK LUNAR CAUSTIC  ***
+
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+  <head>
+    <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
+    <title>
+      The Project Gutenberg eBook of On The Lunar Caustic, by John Higginbottom.
+    </title>
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+
+<pre>
+
+The Project Gutenberg EBook of An Essay on the Application of the Lunar
+Caustic in the Cure of Certain Wounds and Ulcers, by John  Higginbottom
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: An Essay on the Application of the Lunar Caustic in the Cure of Certain Wounds and Ulcers
+
+Author: John  Higginbottom
+
+Release Date: December 4, 2007 [EBook #23729]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK LUNAR CAUSTIC  ***
+
+
+
+
+Produced by Bryan Ness, Jeannie Howse and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+
+</pre>
+
+
+<br />
+<hr />
+<br />
+
+<div class="tr">
+<p class="cen" style="font-weight: bold;">Transcriber's Note:</p>
+<br />
+<p class="noin">Inconsistent hyphenation and archaic spelling in the original document have been preserved.</p>
+<p class="noin">Obvious typographical errors have been corrected. For a complete list, please see the <span style="white-space: nowrap;"><a href="#TN">end of this document</a>.</span></p>
+</div>
+
+<br />
+<hr />
+<br />
+<br />
+<br />
+<br />
+
+<h3>ON THE</h3>
+
+<h1>LUNAR CAUSTIC.</h1>
+
+<br />
+<br />
+<br />
+<br />
+<hr />
+<br />
+
+<h4>AN</h4>
+
+<h2>ESSAY</h2>
+
+<h5>ON THE</h5>
+
+<h2>APPLICATION</h2>
+
+<h4>OF</h4>
+
+<h2>THE LUNAR CAUSTIC,</h2>
+
+<h4>IN THE<br />
+<i>CURE OF CERTAIN</i></h4>
+
+<h2>WOUNDS AND ULCERS.</h2>
+
+<br />
+
+<h4 style="margin-bottom: -1px;">BY</h4>
+<h2 style="margin-top: -1px; margin-bottom: -1px;">JOHN HIGGINBOTTOM,</h2>
+<h3 style="margin-top: -1px; margin-bottom: -1px;"><i>NOTTINGHAM</i>,</h3>
+<h4 style="margin-top: -1px;">MEMBER OF THE ROYAL COLLEGE OF SURGEONS<br />
+OF LONDON.</h4>
+
+<br />
+
+<h5>LONDON:<br />
+PRINTED FOR<br />
+LONGMAN, REES, ORME, BROWN, AND GREEN,<br />
+<i>PATER-NOSTER ROW</i>.<br />
+1826.</h5>
+
+<br />
+<hr />
+<br />
+<br />
+<br />
+<br />
+
+<h5>T. WHEELHOUSE, PRINTER, NOTTINGHAM.</h5>
+
+<br />
+<br />
+<br />
+<br />
+<hr />
+<br />
+<br />
+<br />
+<br />
+
+<h4>TO</h4>
+<h4>MY BROTHER-IN-LAW,</h4>
+
+<h3>MARSHALL HALL, M.D. F.R.S.E.</h3>
+
+<h4>&amp;c. &amp;c.</h4>
+<h4>THIS LITTLE WORK IS INSCRIBED</h4>
+<h4>WITH</h4>
+<h4>GREAT AFFECTION.</h4>
+
+<h6><i>Nottingham, Jan. 6, 1826.</i></h6>
+
+<br />
+<br />
+<br />
+<br />
+<a name="PREFACE" id="PREFACE"></a><hr />
+<span class='pagenum'><a name="Page_vii" id="Page_vii">[vii]</a></span><br />
+
+<h3>PREFACE.</h3>
+<br />
+
+<p>The following pages are presented to the medical public with
+very humble pretensions. It is chiefly with the minor
+accidents or diseases that they have to do; but I shall not
+consider that I have laboured in vain, if I am enabled to
+mitigate even these little evils of human life.</p>
+
+<p>In these prefatory observations, however, I would suggest
+the question whether the caustic may not be employed with
+benefit even in some of the <span class='pagenum'><a name="Page_viii" id="Page_viii">[viii]</a></span>severer diseases to which the
+human frame is liable. Indeed I consider the investigation
+as only just begun, and many other uses of the lunar
+caustic, besides those detailed in the following pages, have
+suggested themselves to me.</p>
+
+<p>May not the caustic, for instance, be of greater efficacy,
+because of greater power and of quicker operation, than
+ordinary blisters, in some internal diseases?</p>
+
+<p>It is repeatedly stated hereafter, that the application of
+the lunar caustic is a means, in certain circumstances, of
+subduing external inflammation. Might it not, on this
+principle, be of service in the treatment of some of the
+internal phlegmasi&aelig;?</p>
+
+<p><span class='pagenum'><a name="Page_ix" id="Page_ix">[ix]</a></span>It may be observed, that the lunar caustic may be regarded,
+almost without further trial, as an effectual preventive of
+those cases of irritative fever which arise from local
+injuries, and probably of the effects of poisoned wounds in
+general. I would not, however, in the latter cases, fail to
+render "sure doubly sure" by free excision.</p>
+
+<p>Might not an adherent eschar be easily formed in those cases
+of compound fracture in which the external wound is of
+moderate size, so as effectually to exclude the external air
+and prevent cutaneous inflammation, and in more respects
+than one, to reduce the case to the state of a simple
+fracture? This object, if attained, would be important
+indeed, and I hope the suggestion will <span class='pagenum'><a name="Page_x" id="Page_x">[x]</a></span>be submitted to the
+most assiduous and cautious trial.</p>
+
+<p>I can have no doubt that the use of the lunar caustic admits
+of being still further extended; and, as I intend to pursue
+the inquiry, I hope at some future period to publish
+something more worthy of the attention of the medical
+public. In the mean time, the plans hereafter suggested must
+not be adopted without that degree of care, attention, and
+perseverance, which are obviously necessary to render them
+successful.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="toc" id="toc"></a><hr />
+<br />
+
+<h3>CONTENTS.</h3>
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="80%" summary="Table of Contents">
+  <tr>
+  <td class="tdl" style="padding-left: 1em;" colspan="2"><a href="#CHAPTER_I">CHAPTER I.</a></td>
+  <td class="tdr" style="font-size: 80%;">PAGE</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="padding-left: 1em; padding-bottom: .5em; font-size: 80%;" colspan="2">ON HEALING BY ESCHAR</td>
+  <td class="tdr">1</td>
+  </tr>
+  <tr>
+  <td class="tdr" width="10%">I.</td>
+  <td class="tdl" width="70%"><i>Of the Adherent Eschar</i></td>
+  <td class="tdr" width="20%"><a href="#Page_3">3</a></td>
+  </tr>
+  <tr>
+  <td class="tdr">II.</td>
+  <td class="tdl"><i>Of the Unadherent Eschar</i></td>
+  <td class="tdr"><a href="#Page_14">14</a></td>
+  </tr>
+  <tr>
+  <td class="tdr">III.</td>
+  <td class="tdl"><i>On the Treatment by Eschar and Poultice</i></td>
+  <td class="tdr"><a href="#Page_21">21</a></td>
+  </tr>
+  <tr>
+  <td class="tdl" style="padding-left: 1em; padding-top: .5em;" colspan="2"><a href="#CHAPTER_II">CHAPTER II.</a></td>
+  <td class="tdr">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="padding-left: 1em; padding-bottom: .5em; font-size: 80%;" colspan="2">OF THE APPLICATION OF THESE MODES OF TREATMENT TO DIFFERENT CASES</td>
+  <td class="tdr">24</td>
+  </tr>
+  <tr>
+  <td class="tdr">I.</td>
+  <td class="tdl"><i>Of Punctures, Bites, &amp;c</i></td>
+  <td class="tdr"><a href="#Page_24">24</a></td>
+  </tr>
+  <tr>
+  <td class="tdr">II.</td>
+  <td class="tdl"><i>Of Bruised Wounds</i></td>
+  <td class="tdr"><a href="#Page_64">64</a></td>
+  </tr>
+  <tr>
+  <td class="tdr">III.</td>
+  <td class="tdl"><i>Of Ulcers</i></td>
+  <td class="tdr"><a href="#Page_82">82</a></td>
+  </tr>
+  <tr>
+  <td class="tdr">IV.</td>
+  <td class="tdl"><i>Of some Anomalous cases</i></td>
+  <td class="tdr"><a href="#Page_120">120</a></td>
+  </tr>
+  <tr>
+  <td class="tdl" style="padding-left: 1em; padding-top: .5em;" colspan="2"><a href="#CHAPTER_III">CHAPTER III.</a></td>
+  <td class="tdr">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="padding-left: 1em; font-size: 80%;" colspan="2">OF SOME CASES IN WHICH THE CAUSTIC IS INAPPLICABLE</td>
+  <td class="tdr">130</td>
+  </tr>
+</table>
+</div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_I" id="CHAPTER_I"></a><hr />
+<span class='pagenum'><a name="Page_1" id="Page_1">[1]</a></span><br />
+
+<h3>CHAPTER I.<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>ON HEALING BY ESCHAR.</h4>
+<br />
+
+
+<p>Having been led, by several circumstances, to try the
+effects of the Lunar Caustic in the treatment of Wounds and
+Ulcers, and having great reason, from these trials, to think
+that this remedy may be used with much advantage far more
+extensively than has hitherto been done, I lay the results
+of my experience before my medical brethren.</p>
+
+<p><span class='pagenum'><a name="Page_2" id="Page_2">[2]</a></span>A very natural mode of healing certain wounds and ulcers, is
+by scabbing; but this mode of treatment is attended by many
+disadvantages, as will be pointed out shortly; yet it may be
+supposed to have suggested to me some of those trials of the
+treatment by eschar, which I am about to detail.</p>
+
+<span class='pagenum'><a name="Page_3" id="Page_3">[3]</a></span><br />
+
+<h4>I. ON THE ADHERENT ESCHAR.</h4>
+
+<p>It appears scarcely necessary to describe the immediate and
+well known effects of the application of the lunar caustic
+to the surface of a wound or ulcer. It may, however, be
+shortly observed that the contact of the caustic induces, at
+first, a white film or eschar which, when exposed to the
+air, assumes in a few hours a darker colour, and at a later
+period, becomes black; as the eschar undergoes these changes
+of colour it gradually becomes harder and resembles a bit of
+sticking plaster; in the course of a few days, according to
+<span class='pagenum'><a name="Page_4" id="Page_4">[4]</a></span>the size and state of the wound, the eschar becomes
+corrugated and begins to separate at its edges, and at
+length peels off altogether, leaving the surface of the sore
+underneath, in a healed state.</p>
+
+<p>In the formation of this eschar several things require
+particular attention. The application of the caustic should
+be made over the whole surface of the sore; and indeed no
+part requires so much attention as the edges; to make a
+firmer eschar the caustic should even be applied beyond the
+edge of the wound, upon the surrounding skin, for the eschar
+in drying is apt to contract a little, and in this manner
+may leave a <span class='pagenum'><a name="Page_5" id="Page_5">[5]</a></span>space between its edges and that of the
+adjacent healthy skin.</p>
+
+<p>At the same time, much attention must be paid to the degree
+in which the caustic is applied. In cases of recent wounds
+unattended by inflammation, it may be applied freely; but
+when inflammation has come on, too severe an application of
+the caustic induces vesication of the surrounding skin, and
+the edges of the eschar may in this manner also be loosened
+and removed. If every part is touched, a slight application
+of the caustic is generally sufficient.</p>
+
+<p><span class='pagenum'><a name="Page_6" id="Page_6">[6]</a></span>The importance of avoiding all causes which might detach the
+edges of the eschar will be apprehended by the following
+interesting observation, which I have been enabled to deduce
+from very extensive trials of the caustic; it is, that, in
+every instance in which the eschar remains adherent from the
+first application, the wound or ulcer over which it is
+formed, invariably heals.</p>
+
+<p>Not only the cause just mentioned, but every other by which
+the eschar might be disturbed, must, therefore, be carefully
+avoided; and especially, as the eschar begins to separate
+from the <span class='pagenum'><a name="Page_7" id="Page_7">[7]</a></span>healed edges of the sore, it should be carefully
+removed by a pair of scissors.</p>
+
+<p>To the surface of the wound the eschar supplies a complete
+protection and defence, and allows the healing process to go
+on underneath uninterruptedly and undisturbed. It renders
+all applications, such as plasters, totally unnecessary, as
+well as the repeated dressings to which recourse is usually
+had in such cases; and it at once removes the soreness
+necessarily attendant on an ulcerated surface being exposed
+to the open air. In many cases too, in which the patients
+are usually rendered incapable of following their wonted
+<span class='pagenum'><a name="Page_8" id="Page_8">[8]</a></span>avocations, this mode of treatment saves them from an
+inconvenience, which is, to some, of no trifling nature.</p>
+
+<p>It has already been stated how important it is that the
+eschar should be preserved adherent. To secure this still
+more effectually, I have found it of great utility to
+protect it by a portion of gold-beater's skin. The skin
+surrounding the wound is simply moistened with a drop of
+water, and the gold-beater's skin is then to be applied over
+it and over the eschar, to which it soon adheres firmly, but
+from which it may be removed at any time, by again
+moistening it for a moment with water; the <span class='pagenum'><a name="Page_9" id="Page_9">[9]</a></span>same bit of
+gold-beater's skin admits of being again and again reapplied
+in the same manner.</p>
+
+<p>The other circumstances which render the eschar unadherent
+will be mentioned hereafter. In the mean time the fact
+stated <span style="white-space: nowrap;"><a href="#Page_6">p. 6</a>,</span> will sufficiently establish the propriety of
+treating distinctly of the adherent eschar.</p>
+
+<p>I now proceed to mention some other effects of the
+application of the caustic. The first is that, in cases in
+which there would be much and long continued irritability
+and pain, as in superficial wounds along the shin, all this
+<span class='pagenum'><a name="Page_10" id="Page_10">[10]</a></span>suffering, and its consequences in disabling the patient,
+are completely avoided. A blush of inflammation forms around
+the eschar, but this gradually subsides without any
+disagreeable consequences, and the inflammation which would
+otherwise have been set up is entirely prevented by the due
+formation of the eschar.</p>
+
+<p>If inflammation be previously established, it is increased,
+at first, by the application of the caustic. But if this
+inflammation be not severe, and if the eschar remain
+adherent, all inflammation, both that induced by the
+application of the caustic, and that existing <span class='pagenum'><a name="Page_11" id="Page_11">[11]</a></span>previously,
+entirely subsides. When the previous inflammation round the
+ulcer is considerable, however, the application of the
+caustic would induce vesication, and it should in such a
+case of course be avoided, and another mode of treatment to
+be described hereafter must be adopted.</p>
+
+<p>I would introduce in this place some observations on the
+comparative effects of healing by eschar and by scabbing. On
+the subject of scabbing I must refer my reader to the well
+known work of Mr. John Hunter. The advantage of healing by
+eschar over that by scabbing is quite decided. By
+comparative trials, <span class='pagenum'><a name="Page_12" id="Page_12">[12]</a></span>I have found that whilst the scab is
+irritable and painful, and surrounded by a ring of
+inflammation, the adherent eschar is totally free from pain
+and inflammation; and that whilst the scab remains attended
+by inflammation and unhealed, the eschar is gradually
+separating, leaving the surface underneath completely
+healed. To these observations I may add that the success of
+the plan of healing by eschar is infinitely more certain as
+well as more speedy than that by scabbing.</p>
+
+<p>I shall, in conclusion, briefly recapitulate the advantages
+of this mode of treatment. In the first place, it will be
+<span class='pagenum'><a name="Page_13" id="Page_13">[13]</a></span>found far more efficacious and speedy than any other;
+secondly, it has the great advantage of saving the patient
+much suffering and inconvenience; and thirdly, it renders
+the repeated application of dressings and ointments quite
+unnecessary. Its utility is extremely great, therefore,
+where the time of the poor, the expense of an establishment,
+and the labours of the medical officer, as well as the
+sufferings of the patient, require to be considered; and it
+will I imagine be found of no little advantage, in all these
+respects, in many cases which are incident to the soldier
+and sailor.</p>
+
+<span class='pagenum'><a name="Page_14" id="Page_14">[14]</a></span><br />
+
+<h4>II. ON THE UNADHERENT ESCHAR.</h4>
+
+<p>The eschar is generally adherent in cases of recent
+injuries, and in small ulcers, when they are nearly even
+with the skin and attended by little inflammation. In other
+cases the eschar is too apt to be unadherent, and this
+arises from the formation of pus or of a scab underneath.</p>
+
+<p>If the eschar be unadherent by subjacent pus, it may be
+ascertained in the space of from twelve to twenty-four
+hours; the centre is generally observed to be raised and to
+yield to the pressure <span class='pagenum'><a name="Page_15" id="Page_15">[15]</a></span>of a probe; sometimes the subjacent
+fluid has partly escaped by an opening at the side of the
+eschar.</p>
+
+<p>When a scab forms underneath the eschar, which does not
+happen except the fluid has been allowed to remain too long
+under the eschar without being evacuated, there are pain and
+some inflammation, the eschar does not separate, but remains
+long over the sore, and there is no appearance of healing.</p>
+
+<p>When it is ascertained that there is fluid underneath the
+eschar, a slight puncture is to be made by the point of a
+penknife, the fluid is to be gently <span class='pagenum'><a name="Page_16" id="Page_16">[16]</a></span>pressed out, and the
+caustic is then to be applied to the orifice thus made. The
+same plan is to be adopted if the fluid ooze out at the edge
+of the eschar; it is to be fully evacuated by pressure, and
+the orifice is to be touched with the caustic. The healing
+process goes on best however when the orifice is in the
+centre of the eschar. After this treatment the eschar
+occasionally remains adherent, but more frequently the fluid
+requires to be evacuated repeatedly, and this should be done
+every twelve hours, or once a day, according to the quantity
+of fluid formed, taking care that the eschar be not
+needlessly separated by allowing the fluid to accumulate
+<span class='pagenum'><a name="Page_17" id="Page_17">[17]</a></span>underneath. If, from accident, the eschar is separated
+before the sore be healed I would reapply the caustic. At
+length the eschar becomes adherent, and in due time begins
+to peel off, leaving the surface healed.</p>
+
+<p>In every case in which the eschar does not separate
+favourably, I begin to suspect the formation of a scab
+underneath, in which case the whole must be removed by the
+application of a cold poultice for two or three days; this
+has not only the effect of removing the eschar but of
+allaying any inflammation or irritation; afterwards the
+caustic must be reapplied as before.</p>
+
+<p><span class='pagenum'><a name="Page_18" id="Page_18">[18]</a></span>The gold-beater's skin is more useful as a protection to the
+unadherent than to the adherent eschar, as the former would
+be more liable to be torn off by accident than the latter.
+The gold-beater's skin must be removed in the manner already
+described, whenever the subjacent fluid is to be evacuated,
+and must be reapplied after touching the orifice with
+caustic.</p>
+
+<p>The pain experienced on the application of the caustic is
+greater or less according to the sensibility and size of the
+wound. In small wounds it is trifling, and of short
+duration; it is more severe in recent wounds than in
+ulcers; <span class='pagenum'><a name="Page_19" id="Page_19">[19]</a></span>it soon subsides in every case, and then the
+patient enjoys greater ease than would be experienced under
+any other mode of treatment. Little or no pain is caused on
+applying the caustic after evacuating the subjacent fluid of
+an unadherent eschar. Altogether the pain inflicted by the
+caustic is far less than is generally imagined, and forms
+scarcely an obstacle to its employment.</p>
+
+<p>It may be proper, in this place, to notice such
+circumstances as render the employment of the caustic
+improper or inefficient. It is improper to employ the
+caustic when the ulcer is too large to admit of the
+formation of a complete <span class='pagenum'><a name="Page_20" id="Page_20">[20]</a></span>eschar; or when it is so situated
+as to render it impossible that the eschar should remain
+undisturbed, as between the toes, unless, indeed, the
+patient be confined to his bed;&mdash;or in cases attended by
+much inflammation, or by much &oelig;dema.</p>
+
+<p>I have found no kind of caustic so manageable as the lunar
+caustic; and this is best applied in the solid form. I have
+thought too, that the newly prepared lunar caustic is more
+apt to dissolve on being applied than that which has been
+longer made and more exposed to the air; the latter is
+therefore to be preferred.</p>
+
+<span class='pagenum'><a name="Page_21" id="Page_21">[21]</a></span><br />
+
+<h4>III. ON THE TREATMENT BY ESCHAR AND POULTICE.</h4>
+
+<p>In many cases in which it is impossible to adopt either the
+mode of treatment by the adherent or the unadherent eschar,
+it is of great utility to apply the caustic first and then a
+cold poultice made without lard or oil: this plan is
+particularly useful in cases of punctured wounds attended by
+much pain and swelling, and in cases of recently opened
+abscesses. By this application the pain and swelling are
+much subdued and a free issue is secured for the secreted
+fluid; and in no case have I seen the original inflammation
+increased by it.</p>
+
+<p><span class='pagenum'><a name="Page_22" id="Page_22">[22]</a></span>It is generally necessary to repeat the application of the
+caustic every second or third day, or every day if the
+inflammation and swelling of the part be considerable, and
+the cold poultice may be renewed about every eight hours. At
+length, however, the inflammation having subsided, the
+attempt may be made to form an adherent eschar.</p>
+
+<p>I have seen many cases, in which, by this mode of treatment,
+much suffering and perhaps the loss of some of the smaller
+joints have been prevented, particularly cases of deep
+seated inflammation of the fingers, which, having <span class='pagenum'><a name="Page_23" id="Page_23">[23]</a></span>been
+neglected, have issued in severe inflammation, abscess, and
+terrible fungous growths. In these cases it is not only
+necessary to apply the caustic to the surface of the sore,
+but in every cavity or orifice which may be formed by the
+disease.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_II" id="CHAPTER_II"></a><hr />
+<span class='pagenum'><a name="Page_24" id="Page_24">[24]</a></span><br />
+
+<h3>CHAPTER II.<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>ON THE APPLICATION OF THESE MODES OF TREATMENT TO PARTICULAR
+CASES.</h4>
+
+<br />
+
+<h4>I. OF PUNCTURES ETC.</h4>
+
+<p>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 <span class='pagenum'><a name="Page_25" id="Page_25">[25]</a></span>completely the terrible effects of a
+punctured wound are prevented; the eschar usually remains
+adherent, and the case requires no further attention.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_26" id="Page_26">[26]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>In cases of puncture where the orifice is healed and where
+an <span class='pagenum'><a name="Page_27" id="Page_27">[27]</a></span>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.</p>
+
+<p>This mode of treatment is particularly useful in cases of
+punctured and lacerated wounds from various instruments,
+such as needles, nails, hooks, bayonets, saws, &amp;c. and in
+the bites of animals, leech-bites, stings of insects, &amp;c. In
+considerable lacerations the same objection would exist to
+this treatment as in large ulcers.</p>
+
+<p><span class='pagenum'><a name="Page_28" id="Page_28">[28]</a></span>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.</p>
+
+<p>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.</p>
+
+<br />
+
+<h4 class="sc"><span class='pagenum'><a name="Page_29" id="Page_29">[29]</a></span>Case I.</h4>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_30" id="Page_30">[30]</a></span>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_31" id="Page_31">[31]</a></span>From this time the eschar remained adherent, and at length
+gradually separated leaving the part perfectly well.</p>
+
+<p>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.</p>
+
+<br />
+
+<h4 class="sc"><span class='pagenum'><a name="Page_32" id="Page_32">[32]</a></span>Case II.</h4>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_33" id="Page_33">[33]</a></span>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_34" id="Page_34">[34]</a></span>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.</p>
+
+<br />
+
+<h4 class="sc">Case III.</h4>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_35" id="Page_35">[35]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>The eschar was at length removed by the healing process and
+was separated together with the nail, and the case <span class='pagenum'><a name="Page_36" id="Page_36">[36]</a></span>was
+unattended by any further inconvenience or trouble either to
+the patient or myself.</p>
+
+<p>It is scarcely necessary to contrast the advantage of this
+mode of treatment with that by plasters, poultices, &amp;c. It
+is at once more speedy and secure, and less cumbersome to
+such patients as are obliged to continue domestic
+avocations.</p>
+
+<br />
+
+<h4 class="sc">Case IV.</h4>
+
+<p>The present case is somewhat more severe than those which
+have been already given, and what is of great <span class='pagenum'><a name="Page_37" id="Page_37">[37]</a></span>importance,
+the caustic was not applied immediately after the accident.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_38" id="Page_38">[38]</a></span>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.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_39" id="Page_39">[39]</a></span>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,&mdash;for had
+this been attempted in this case, suppuration would
+doubtless have taken place from the closed state of the
+puncture by the swelling;&mdash;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.</p>
+
+<p>The following case is not less instructive.</p>
+
+<br />
+
+<h4 class="sc"><span class='pagenum'><a name="Page_40" id="Page_40">[40]</a></span>Case V.</h4>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_41" id="Page_41">[41]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>In such cases the caustic unites the advantages of at once
+opening the puncture and of subduing the inflammation, <span class='pagenum'><a name="Page_42" id="Page_42">[42]</a></span>thus
+preventing the formation of deep-seated abscesses.</p>
+
+<br />
+
+<h4 class="sc">Case VI.</h4>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_43" id="Page_43">[43]</a></span>On the next day, the inflammation had greatly subsided; the
+cataplasm and lotion were continued.</p>
+
+<p>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.</p>
+
+<p>On the fourth day the swelling was subsiding and there was
+no pain. The poultice and lotion were continued.&mdash;From this
+time there was no occasion for any remedy, and the little
+patient speedily recovered.</p>
+
+<br />
+
+<h4 class="sc"><span class='pagenum'><a name="Page_44" id="Page_44">[44]</a></span>Case VII.</h4>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_45" id="Page_45">[45]</a></span>the
+puncture; a free incision was made, and some pus was
+evacuated.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_46" id="Page_46">[46]</a></span>these openings, and reapplied a cold
+poultice and lotion.</p>
+
+<p>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.</p>
+
+<p>From this time, I found nothing necessary but to repeat the
+application of the caustic about every third day to <span class='pagenum'><a name="Page_47" id="Page_47">[47]</a></span>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.</p>
+
+<p>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.</p>
+
+<br />
+
+<h4 class="sc"><span class='pagenum'><a name="Page_48" id="Page_48">[48]</a></span>Case VIII.</h4>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_49" id="Page_49">[49]</a></span>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_50" id="Page_50">[50]</a></span>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.</p>
+
+<p>On the 13th the swelling and pain were nearly gone. I
+repeated the caustic which induced bleeding from the fungous
+flesh.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_51" id="Page_51">[51]</a></span>On the 15th the fungous was nearly removed; the wound
+presented an appearance of slough over its surface.&mdash;The
+caustic was applied to the remaining fungous.</p>
+
+<p>On the 17th the wound was much smaller and the slough
+separating. The caustic and cataplasm were applied as
+before.&mdash;A similar report was made on the succeeding day.</p>
+
+<p>On the 20th the slough was separating. The caustic and
+cataplasm were applied.&mdash;A similar report was made on the
+22d.</p>
+
+<p><span class='pagenum'><a name="Page_52" id="Page_52">[52]</a></span>On the 24th the slough having separated the integuments over
+it were flabby and loose; the caustic was applied to them.</p>
+
+<p>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.</p>
+
+<br />
+<hr style='width: 15%;' />
+<br />
+
+<p>I shall in this place, introduce a few observations on
+wounds received during dissection.</p>
+
+<p><span class='pagenum'><a name="Page_53" id="Page_53">[53]</a></span>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_54" id="Page_54">[54]</a></span>The following is the exact mode of treatment which I would
+adopt in such cases.</p>
+
+<p>In recent punctures the caustic should be applied in the
+manner already described in cases of simple punctured
+wounds.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_55" id="Page_55">[55]</a></span>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.</p>
+
+<br />
+<hr style='width: 15%;' />
+<br />
+
+<p>In connexion with punctured wounds I here subjoin several
+cases of the bites of animals.</p>
+
+<br />
+
+<h4 class="sc">Case IX.</h4>
+
+<p>James Joynes, aged 12, was bitten by an ass, on each side of
+the middle <span class='pagenum'><a name="Page_56" id="Page_56">[56]</a></span>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.</p>
+
+<p>On the succeeding day, the eschar was found to be quite
+adherent, and the pain and swelling had subsided.</p>
+
+<p>The eschar separated in about twelve days and the wounds
+were healed.</p>
+
+<br />
+
+<h4 class="sc">Case X.</h4>
+
+<p>Mr. Worth's daughter, aged six, was thrown down by a dog and
+bitten <span class='pagenum'><a name="Page_57" id="Page_57">[57]</a></span>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.</p>
+
+<p>On the next day the eschars were adherent. There was some
+swelling from the severity of the bruise; but the child made
+little complaint.</p>
+
+<p>On the third day, the swelling remained as before and the
+eschar <span class='pagenum'><a name="Page_58" id="Page_58">[58]</a></span>adherent. On the fourth, the swelling had nearly
+disappeared.&mdash;The eschar separated in nine days from the
+infliction of the wound, leaving the parts healed and free
+from scar.</p>
+
+<br />
+
+<h4 class="sc">Case XI.</h4>
+
+<p>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.</p>
+
+<p>On the succeeding day, I found that the patient had applied
+a little lint <span class='pagenum'><a name="Page_59" id="Page_59">[59]</a></span>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.</p>
+
+<p>The eschar remained adherent, the inflammation subsided and
+the case gave no further trouble.</p>
+
+<br />
+
+<h4 class="sc">Case XII.</h4>
+
+<p>A servant maid was bitten by a dog in four places&mdash;severely
+on the forearm&mdash;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, <span class='pagenum'><a name="Page_60" id="Page_60">[60]</a></span>attended by
+dull pain, and swelling of the arm. I applied the caustic to
+form an eschar, covering it with goldbeater's skin.</p>
+
+<p>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.</p>
+
+<p>On the next day the swelling had subsided. The eschar had
+the same character; a little fluid was again <span class='pagenum'><a name="Page_61" id="Page_61">[61]</a></span>evacuated and
+the caustic applied to the orifice as before.</p>
+
+<p>This mode of treatment was pursued for nine successive days
+when the eschar remained adherent in every part.</p>
+
+<p>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.</p>
+
+<p>Adherent eschars were formed on the other three bites which
+were less severe, from the first application.</p>
+
+<p><span class='pagenum'><a name="Page_62" id="Page_62">[62]</a></span>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.</p>
+
+<br />
+
+<h4 class="sc">Case XIII.</h4>
+
+<p>Am old man applied leeches to the instep for inflammation
+occasioned by a bruise. Several very irritable sores were
+produced with some swelling. I <span class='pagenum'><a name="Page_63" id="Page_63">[63]</a></span>applied the lunar caustic to
+form an eschar.</p>
+
+<p>On the following day, the eschars were adherent, the
+swelling had subsided, and he had slept well for the first
+time of several nights.</p>
+
+<p>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.</p>
+
+<span class='pagenum'><a name="Page_64" id="Page_64">[64]</a></span><br />
+
+<h4>II. ON BRUISES.</h4>
+
+<p>It has been already observed, <span style="white-space: nowrap;"><a href="#Page_9">p. 9</a>,</span> 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, <span class='pagenum'><a name="Page_65" id="Page_65">[65]</a></span>arising out of the tendency
+observed in them, to the formation of a slough.</p>
+
+<p>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 <span class='pagenum'><a name="Page_66" id="Page_66">[66]</a></span>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_67" id="Page_67">[67]</a></span>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_68" id="Page_68">[68]</a></span>induce
+vesication of the skin, as I have mentioned already, <span style="white-space: nowrap;"><a href="#Page_5">p. 5</a>,</span>
+and the eschar could not be adherent.</p>
+
+<br />
+
+<h4 class="sc">Case XIV.</h4>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_69" id="Page_69">[69]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>On the third day there was no pain or inflammation, and the
+eschar remained adherent.</p>
+
+<p><span class='pagenum'><a name="Page_70" id="Page_70">[70]</a></span>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.</p>
+
+<br />
+
+<h4 class="sc">Case XV.</h4>
+
+<p>The following case was far more severe, but the mode of
+treatment was not less efficacious.</p>
+
+<p>Mr. Granger, aged 36, was exposed to a severe bruise by a
+great weight of stones which had been piled up, falling
+<span class='pagenum'><a name="Page_71" id="Page_71">[71]</a></span>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.</p>
+
+<p><span class='pagenum'><a name="Page_72" id="Page_72">[72]</a></span>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.</p>
+
+<p>On the third day, the swelling had abated. No further
+remedy. The patient was still enjoined to rest.</p>
+
+<p>On the fourth day the swelling was nearly gone. The eschar
+remained adherent. The patient walks about.</p>
+
+<p>From this time the patient pursued his avocation of a
+stone-mason; no <span class='pagenum'><a name="Page_73" id="Page_73">[73]</a></span>further remedy was required; no
+inconvenience experienced; and the eschar separated in about
+a month.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<br />
+
+<h4 class="sc"><span class='pagenum'><a name="Page_74" id="Page_74">[74]</a></span>Case XVI.</h4>
+
+<p>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.</p>
+
+<p>On the following day the eschar was found to be adherent,
+and there was neither pain nor swelling.</p>
+
+<p>The eschars separated in nine days leaving the wounds
+healed.</p>
+
+<p><span class='pagenum'><a name="Page_75" id="Page_75">[75]</a></span>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.</p>
+
+<br />
+
+<h4 class="sc">Case XVII.</h4>
+
+<p>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.</p>
+
+<p>On the next day an adherent eschar was formed. There was
+neither pain <span class='pagenum'><a name="Page_76" id="Page_76">[76]</a></span>nor swelling.&mdash;The eschar separated in a
+fortnight.</p>
+
+<br />
+
+<h4 class="sc">Case XVIII.</h4>
+
+<p>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 <span class='pagenum'><a name="Page_77" id="Page_77">[77]</a></span>very
+doubtful, from the same cause, whether it would be adherent
+or no.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>In regard to the inflammation attendant on these wounds, I
+would <span class='pagenum'><a name="Page_78" id="Page_78">[78]</a></span>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.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_79" id="Page_79">[79]</a></span>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.</p>
+
+<br />
+
+<h4 class="sc">Case XIX.</h4>
+
+<p>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 <span class='pagenum'><a name="Page_80" id="Page_80">[80]</a></span>and
+directed the part to be exposed to the cold air.</p>
+
+<p>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.</p>
+
+<p>On the third day there was still further amendment. From
+this time no remedy or attention was required.</p>
+
+<br />
+
+<h4 class="sc">Case XX.</h4>
+
+<p>It frequently occurs to surgeons to receive slight wounds
+upon the hands <span class='pagenum'><a name="Page_81" id="Page_81">[81]</a></span>which prove very troublesome. Of this kind
+is the following.</p>
+
+<p>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.</p>
+
+<p>From this time the pain and inflammation subsided. The
+eschar remained firm and adherent, and in six days separated
+leaving the wound healed.</p>
+
+<span class='pagenum'><a name="Page_82" id="Page_82">[82]</a></span><br />
+
+<h4>III. ON ULCERS.</h4>
+
+<p>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.</p>
+
+<p>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; <span class='pagenum'><a name="Page_83" id="Page_83">[83]</a></span>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.</p>
+
+<p>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; <span class='pagenum'><a name="Page_84" id="Page_84">[84]</a></span>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_85" id="Page_85">[85]</a></span>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.</p>
+
+<p><span class='pagenum'><a name="Page_86" id="Page_86">[86]</a></span>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.</p>
+
+<br />
+
+<h4 class="sc">Case XXI.</h4>
+
+<p>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. <span class='pagenum'><a name="Page_87" id="Page_87">[87]</a></span>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_88" id="Page_88">[88]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_89" id="Page_89">[89]</a></span>On the next day the smaller eschar was quite adherent; under
+the large one, there was still a very little fluid.</p>
+
+<p>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.&mdash;In the course of time the eschar separated
+completely, leaving the ulcers healed.</p>
+
+<p>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.</p>
+
+<br />
+
+<h4 class="sc"><span class='pagenum'><a name="Page_90" id="Page_90">[90]</a></span>Case XXII.</h4>
+
+<p>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 <span class='pagenum'><a name="Page_91" id="Page_91">[91]</a></span>the
+lunar caustic upon each ulcer, but not over the excoriation,
+and I enjoined the patient to leave the whole exposed to
+dry.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_92" id="Page_92">[92]</a></span>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.</p>
+
+<p>In four days after the last report, most of the eschars had
+separated from the smallest ulcers leaving the parts healed.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_93" id="Page_93">[93]</a></span>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.</p>
+
+<p>Five days after this period, I again observed a disposition
+to excoriate. I applied the caustic.</p>
+
+<p>In two days more, the eschars were adherent, and there was
+no further appearance of excoriation.</p>
+
+<p>In ten more days, the eschars had separated and all the
+ulcers and excoriations were completely healed.</p>
+
+<p><span class='pagenum'><a name="Page_94" id="Page_94">[94]</a></span>This case occurred several years ago, and there has been no
+return of the affliction whatever.</p>
+
+<br />
+
+<h4 class="sc">Case XXIII.</h4>
+
+<p>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.&mdash;From the small size
+of the ulcer, I applied the lunar caustic and protected the
+eschar by the gold-beater's skin.</p>
+
+<p><span class='pagenum'><a name="Page_95" id="Page_95">[95]</a></span>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_96" id="Page_96">[96]</a></span>the eschar as before and
+required evacuating thrice; but at length the eschar
+adhered, and in due time separated leaving the ulcer quite
+healed.</p>
+
+<p>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.</p>
+
+<br />
+
+<h4 class="sc">Case XXIV.</h4>
+
+<p>The following case must not be regarded as altogether
+trifling. For such <span class='pagenum'><a name="Page_97" id="Page_97">[97]</a></span>sores are very apt to spread and to
+remain long very troublesome.</p>
+
+<p>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.</p>
+
+<p>The eschar separated in about three weeks leaving the part
+healed.</p>
+
+<br />
+
+<h4 class="sc"><span class='pagenum'><a name="Page_98" id="Page_98">[98]</a></span>Case XXV.</h4>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_99" id="Page_99">[99]</a></span>interval. There were some &oelig;dema
+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.</p>
+
+<p>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 &oelig;dema. This project was deferred, <span class='pagenum'><a name="Page_100" id="Page_100">[100]</a></span>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.</p>
+
+<p><span class='pagenum'><a name="Page_101" id="Page_101">[101]</a></span>When the inflammation had again subsided, I ventured,
+notwithstanding the &oelig;dema, to apply the lunar caustic to
+form an eschar, enjoining rest and the horizontal position.</p>
+
+<p>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.</p>
+
+<p>On the second day, rather more fluid was evacuated in the
+same manner. There was a little more inflammation round the
+eschar than yesterday.</p>
+
+<p><span class='pagenum'><a name="Page_102" id="Page_102">[102]</a></span>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.</p>
+
+<p>On the fifth day, there were less inflammation and
+discharge.</p>
+
+<p>From this day until the tenth the fluid required daily
+evacuation; the eschar became adherent, and I allowed my
+patient to walk about.</p>
+
+<p>In about six weeks the eschar was nearly separated and I
+removed it by <span class='pagenum'><a name="Page_103" id="Page_103">[103]</a></span>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.</p>
+
+<br />
+
+<h4 class="sc">Case XXVI.</h4>
+
+<p>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, <span class='pagenum'><a name="Page_104" id="Page_104">[104]</a></span>therefore, the more remarkable,
+and saved her much trouble and suffering.</p>
+
+<p>Mrs. C. aged 40, had two small irritable and inflamed
+ulcers, under the inner ankle. I applied the lunar caustic
+to form an eschar.</p>
+
+<p>It was requisite to evacuate a little fluid from under the
+eschars for three successive days; they then remained
+adherent.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_105" id="Page_105">[105]</a></span>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.</p>
+
+<br />
+
+<h4 class="sc">Case XXVII.</h4>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_106" id="Page_106">[106]</a></span>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.</p>
+
+<p>On the succeeding day an adherent eschar existed over all
+the ulcerated parts, and the pain, redness, and irritation
+had nearly subsided.</p>
+
+<p>On the fourth day there was still less pain and
+inflammation. On the <span class='pagenum'><a name="Page_107" id="Page_107">[107]</a></span>eight the eschars had separated and
+the breast was quite well.</p>
+
+<br />
+
+<h4 class="sc">Case XXVIII.</h4>
+
+<p>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; <span class='pagenum'><a name="Page_108" id="Page_108">[108]</a></span>the &oelig;dema increases towards night. She has been
+in the habit of taking saline purgatives frequently.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_109" id="Page_109">[109]</a></span>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_110" id="Page_110">[110]</a></span>penknife without
+breaking them, as they had become too hard and thick by
+delay and the addition of the scab.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_111" id="Page_111">[111]</a></span>and purge, and a cold
+poultice and lotion.</p>
+
+<p>In the space of a week I again attempted to form an eschar
+over the larger wound, for the smaller one had quite healed.</p>
+
+<p>The next day I discharged a little fluid from the centre,
+and again on the eight or nine succeeding days, giving
+saline purgatives.</p>
+
+<p>After this time the eschar remained adherent, and no further
+remedy was required.</p>
+
+<p><span class='pagenum'><a name="Page_112" id="Page_112">[112]</a></span>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,&mdash;apply the
+poultice,&mdash;and recur to the caustic in the course of a few
+days.</p>
+
+<p>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 <span class='pagenum'><a name="Page_113" id="Page_113">[113]</a></span>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.</p>
+
+<br />
+
+<h4 class="sc">Case XXIX.</h4>
+
+<p>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, <span class='pagenum'><a name="Page_114" id="Page_114">[114]</a></span>without
+however being entirely detached.</p>
+
+<p>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.</p>
+
+<p>On the following day, it appeared from the flatness of the
+surface, that the eschar was adherent; the inflammation
+remained as before.</p>
+
+<p>On the next day the eschar was raised all round its borders,
+presenting <span class='pagenum'><a name="Page_115" id="Page_115">[115]</a></span>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.</p>
+
+<p>On the succeeding day an opening was made in the centre of
+the eschar and a little more fluid was evacuated.</p>
+
+<p>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 <span class='pagenum'><a name="Page_116" id="Page_116">[116]</a></span>detached the eschar; there was
+still, however, a minute ulcer left, which was touched with
+the caustic.</p>
+
+<br />
+
+<h4 class="sc">Case XXX.</h4>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_117" id="Page_117">[117]</a></span>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.</p>
+
+<p>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, <span class='pagenum'><a name="Page_118" id="Page_118">[118]</a></span>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.</p>
+
+<br />
+
+<h4 class="sc">Case XXXI.</h4>
+
+<p>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.</p>
+
+<p>The day afterwards, I found the eschar incomplete and I
+applied the <span class='pagenum'><a name="Page_119" id="Page_119">[119]</a></span>caustic again. The eschar was still incomplete
+on the following day, and the caustic was again required to
+be applied to the denuded parts.</p>
+
+<p>On examination two days afterwards I found the eschar
+complete and adherent.</p>
+
+<p>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.</p>
+
+<span class='pagenum'><a name="Page_120" id="Page_120">[120]</a></span><br />
+
+<h4>IV. OF SOME ANOMALOUS CASES.</h4>
+
+<p class="cen">1. <i>Of Whitlow.</i></p>
+
+<p>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 <span class='pagenum'><a name="Page_121" id="Page_121">[121]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>In those cases in which the suppuration is artificial and
+attended with <span class='pagenum'><a name="Page_122" id="Page_122">[122]</a></span>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; <span style="white-space: nowrap;"><a href="#Page_11">see p. 11</a>;</span> afterwards the skin
+may be removed, and if there be excoriations the caustic may
+be lightly applied.</p>
+
+<br />
+
+<p class="cen">2. <i>Of Inflammation of the Finger.</i></p>
+
+<p>The following case of inflammation of the finger occurred
+without any assignable cause.</p>
+
+<br />
+
+<h4 class="sc">Case XXXI.</h4>
+
+<p>A young man, aged 18, came to me with a painful swelling of
+the middle <span class='pagenum'><a name="Page_123" id="Page_123">[123]</a></span>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.</p>
+
+<p>On the fourth day my patient had returned to his occupation
+as a dyer.</p>
+
+<br />
+
+<h4 class="sc">Case XXXII.</h4>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_124" id="Page_124">[124]</a></span>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.</p>
+
+<p>I now applied the caustic freely within the orifice.</p>
+
+<p>On the following day there was less swelling and discharge.</p>
+
+<p>Two days afterwards, the caustic was again applied, and in
+eight days from the first application of the caustic the
+hand was quite well.</p>
+
+<span class='pagenum'><a name="Page_125" id="Page_125">[125]</a></span><br />
+
+<p class="cen">3. <i>Of Fungous Ulcer of the Navel in Infants.</i></p>
+
+<p>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.</p>
+
+<p>The fungus is to be completely removed by a pair of
+scissors, and when the bleeding has quite ceased, the lunar
+<span class='pagenum'><a name="Page_126" id="Page_126">[126]</a></span>caustic is to be applied, and the part defended by the
+gold-beater's skin and kept carefully from any moisture.</p>
+
+<p>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.</p>
+
+<br />
+
+<p class="cen">4. <i>Of Inflammation of the Knee.</i></p>
+
+<p>Servant women, I suspect from much kneeling in scouring
+stairs, &amp;c. are subject to a species of inflammation of the
+knee which is frequently extremely troublesome.</p>
+
+<p><span class='pagenum'><a name="Page_127" id="Page_127">[127]</a></span>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_128" id="Page_128">[128]</a></span>In a few days all inflammation subsided and the patients
+remained well.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<span class='pagenum'><a name="Page_129" id="Page_129">[129]</a></span><br />
+
+<p class="cen">5. <i>Of Tinea Capitis, &amp;c.</i></p>
+
+<p>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.</p>
+
+<p>The same observation applies to some other cutaneous
+affections which I need not specify more particularly at the
+present.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_III" id="CHAPTER_III"></a><hr />
+<span class='pagenum'><a name="Page_130" id="Page_130">[130]</a></span><br />
+
+<h3>CHAPTER III.<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>OF SOME CASES IN WHICH THE CAUSTIC IS INAPPLICABLE.</h4>
+<br />
+
+<p>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 in <span class='pagenum'><a name="Page_131" id="Page_131">[131]</a></span>which cases it is not, useful and
+successful.</p>
+
+<p>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.</p>
+
+<p>This observation is particularly applicable to the cases of
+burns, of large ulcers, of fungous ulcers, &amp;c.</p>
+
+<p><span class='pagenum'><a name="Page_132" id="Page_132">[132]</a></span>The caustic is inapplicable in extensive lacerations, for
+the same reason that it is so in extensive ulcers.</p>
+
+<p>I have found the caustic of little use in incised wounds,
+and should not employ it except in such wounds received in
+dissection.</p>
+
+<p>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.</p>
+
+<p>In erysipelatous inflammation, where vesicles are formed,
+the caustic does injury, as in recent burns.</p>
+
+<p><span class='pagenum'><a name="Page_133" id="Page_133">[133]</a></span>I have always found that the caustic has done injury in
+boils, aggravating rather than diminishing the affection.</p>
+
+<br />
+
+<p class="cen">1. <i>Of Burns.</i></p>
+
+<p>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
+ulcerated <span class='pagenum'><a name="Page_134" id="Page_134">[134]</a></span>surface 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.</p>
+
+<p>It may be well to illustrate these points, by the following
+cases.</p>
+
+<br />
+
+<h4 class="sc">Case XXXIII.</h4>
+
+<p>A little girl, aged 10, scalded her breast a week ago and
+has treated it <span class='pagenum'><a name="Page_135" id="Page_135">[135]</a></span>with 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.</p>
+
+<p>On the following day, an adherent eschar had formed, and in
+five days more it dropped off leaving the ulcer quite
+healed.</p>
+
+<br />
+
+<h4 class="sc">Case XXXIV.</h4>
+
+<p>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 of <span class='pagenum'><a name="Page_136" id="Page_136">[136]</a></span>three 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 &oelig;dema 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.</p>
+
+<p>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 rather <span class='pagenum'><a name="Page_137" id="Page_137">[137]</a></span>less inflammation and swelling. The
+patient had kept in bed. I prescribed a pill with the
+hydrarg. submurias, to be followed by an aperient draught.</p>
+
+<p>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.</p>
+
+<p>During the two following days the inflammation subsided
+entirely; I evacuated a little fluid from beneath the
+eschar.</p>
+
+<p><span class='pagenum'><a name="Page_138" id="Page_138">[138]</a></span>On the next day the eschar appeared adherent, except in the
+centre which was occupied by the slough.</p>
+
+<p>On the succeeding day, I evacuated a little fluid from
+beneath the slough.</p>
+
+<p>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.</p>
+
+<p>From this time it was necessary to evacuate a little fluid
+from under the eschar for ten successive days. It then
+<span class='pagenum'><a name="Page_139" id="Page_139">[139]</a></span>became adherent, and in about a fortnight it separated,
+leaving the ulcer healed.</p>
+
+<br />
+
+<h4 class="sc">Case XXXV.</h4>
+
+<p>The following case will present a specimen of my trials of
+the lunar caustic in larger ulcers.</p>
+
+<p>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 in <span class='pagenum'><a name="Page_140" id="Page_140">[140]</a></span>diameter 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.</p>
+
+<p>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.</p>
+
+<p>On the following day the eschar appeared tolerably complete
+in the centre <span class='pagenum'><a name="Page_141" id="Page_141">[141]</a></span>but had separated at one part of the
+circumference. I again applied the caustic to the defective
+part.</p>
+
+<p>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.</p>
+
+<p>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
+a <span class='pagenum'><a name="Page_142" id="Page_142">[142]</a></span>detached state. I removed the loose portions and repeated
+the application of the caustic.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_143" id="Page_143">[143]</a></span>In another similar case, I removed the elevated hard edges
+of the ulcer by the lancet, and then tried the caustic,
+without better success.</p>
+
+<br />
+
+<h4 class="sc">Case XXXVI.</h4>
+
+<p>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.</p>
+
+<p>Mrs. H. aged 56, has had very extensive phagedenic
+ulcerations on the <span class='pagenum'><a name="Page_144" id="Page_144">[144]</a></span>legs 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 local <span class='pagenum'><a name="Page_145" id="Page_145">[145]</a></span>applications, the white bread poultice had
+afforded most relief.</p>
+
+<p>I applied the lunar caustic to two of the smaller ulcers.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_146" id="Page_146">[146]</a></span>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.</p>
+
+<p>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 ulcers <span class='pagenum'><a name="Page_147" id="Page_147">[147]</a></span>were
+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.</p>
+
+<br />
+<br />
+<br />
+<br />
+
+<h4>FINIS.</h4>
+
+<br />
+<br />
+<br />
+<br />
+<hr />
+<br />
+<br />
+<br />
+<br />
+
+<h5>T. Wheelhouse, Printer,<br />
+Nottingham.</h5>
+
+<br />
+<hr />
+<br />
+
+<div class="tr">
+<p class="cen"><a name="TN" id="TN"></a>Typographical errors corrected in text:</p>
+<br />
+Page &nbsp;&nbsp;41: &nbsp;&nbsp;cautic replaced with caustic<br />
+Page &nbsp;&nbsp;65: &nbsp;&nbsp;eurative replaced with curative<br />
+Page 107: &nbsp;&nbsp;smuch replaced with much<br />
+Page 120: &nbsp;&nbsp;ANOMOLOUS replaced with ANOMALOUS<br />
+</div>
+
+<br />
+<hr />
+<br />
+
+
+
+
+
+
+
+
+<pre>
+
+
+
+
+
+End of the Project Gutenberg EBook of An Essay on the Application of the
+Lunar Caustic in the Cure of Certain Wounds and Ulcers, by John  Higginbottom
+
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+</body>
+</html>
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@@ -0,0 +1,2261 @@
+The Project Gutenberg EBook of An Essay on the Application of the Lunar
+Caustic in the Cure of Certain Wounds and Ulcers, by John  Higginbottom
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: An Essay on the Application of the Lunar Caustic in the Cure of Certain Wounds and Ulcers
+
+Author: John  Higginbottom
+
+Release Date: December 4, 2007 [EBook #23729]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK LUNAR CAUSTIC  ***
+
+
+
+
+Produced by Bryan Ness, Jeannie Howse and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+book was produced from scanned images of public domain
+material from the Google Print project.)
+
+
+
+
+
+
+       *       *       *       *       *
+
+    +--------------------------------------------------------+
+    |   Transcriber's Note:                                  |
+    |                                                        |
+    |   Inconsistent hyphenation and archaic spelling in     |
+    |   the original document has been preserved.            |
+    |                                                        |
+    |   Obvious typographical errors have been corrected.    |
+    |   For a complete list, please see the end of this      |
+    |   document.                                            |
+    |                                                        |
+    +--------------------------------------------------------+
+
+       *       *       *       *       *
+
+
+
+ON THE
+
+LUNAR CAUSTIC.
+
+
+
+
+AN
+ESSAY
+ON THE
+APPLICATION
+OF
+THE LUNAR CAUSTIC,
+IN THE
+_CURE OF CERTAIN_
+WOUNDS AND ULCERS.
+
+BY
+JOHN HIGGINBOTTOM,
+_NOTTINGHAM_,
+MEMBER OF THE ROYAL COLLEGE OF SURGEONS
+OF LONDON.
+
+LONDON:
+PRINTED FOR
+LONGMAN, REES, ORME, BROWN, AND GREEN,
+_PATER-NOSTER ROW_.
+1826.
+
+
+
+
+T. WHEELHOUSE, PRINTER, NOTTINGHAM.
+
+
+
+
+TO
+MY BROTHER-IN-LAW,
+
+MARSHALL HALL, M.D. F.R.S.E.
+
+&c. &c.
+THIS LITTLE WORK IS INSCRIBED
+WITH
+GREAT AFFECTION.
+
+_Nottingham, Jan. 6, 1826._
+
+
+
+
+PREFACE.
+
+
+The following pages are presented to the medical public with very
+humble pretensions. It is chiefly with the minor accidents or diseases
+that they have to do; but I shall not consider that I have laboured in
+vain, if I am enabled to mitigate even these little evils of human
+life.
+
+In these prefatory observations, however, I would suggest the question
+whether the caustic may not be employed with benefit even in some of
+the severer diseases to which the human frame is liable. Indeed I
+consider the investigation as only just begun, and many other uses of
+the lunar caustic, besides those detailed in the following pages, have
+suggested themselves to me.
+
+May not the caustic, for instance, be of greater efficacy, because of
+greater power and of quicker operation, than ordinary blisters, in
+some internal diseases?
+
+It is repeatedly stated hereafter, that the application of the lunar
+caustic is a means, in certain circumstances, of subduing external
+inflammation. Might it not, on this principle, be of service in the
+treatment of some of the internal phlegmasiae?
+
+It may be observed, that the lunar caustic may be regarded, almost
+without further trial, as an effectual preventive of those cases of
+irritative fever which arise from local injuries, and probably of the
+effects of poisoned wounds in general. I would not, however, in the
+latter cases, fail to render "sure doubly sure" by free excision.
+
+Might not an adherent eschar be easily formed in those cases of
+compound fracture in which the external wound is of moderate size, so
+as effectually to exclude the external air and prevent cutaneous
+inflammation, and in more respects than one, to reduce the case to the
+state of a simple fracture? This object, if attained, would be
+important indeed, and I hope the suggestion will be submitted to the
+most assiduous and cautious trial.
+
+I can have no doubt that the use of the lunar caustic admits of being
+still further extended; and, as I intend to pursue the inquiry, I hope
+at some future period to publish something more worthy of the
+attention of the medical public. In the mean time, the plans hereafter
+suggested must not be adopted without that degree of care, attention,
+and perseverance, which are obviously necessary to render them
+successful.
+
+
+
+
+CONTENTS.
+
+
+CHAPTER I.
+                                                             PAGE
+ON HEALING BY ESCHAR                                            1
+
+  I. _Of the Adherent Eschar_                                   3
+ II. _Of the Unadherent Eschar_                                14
+III. _On the Treatment by Eschar and Poultice_                 21
+
+
+CHAPTER II.
+
+OF THE APPLICATION OF THESE MODES OF TREATMENT TO
+DIFFERENT CASES                                                24
+
+  I. _Of Punctures, Bites, &c_                                 24
+ II. _Of Bruised Wounds_                                       64
+III. _Of Ulcers_                                               82
+ IV. _Of some Anomalous cases_                                120
+
+
+CHAPTER III.
+
+OF SOME CASES IN WHICH THE CAUSTIC IS INAPPLICABLE            130
+
+
+
+
+CHAPTER I.
+
+ON HEALING BY ESCHAR.
+
+
+Having been led, by several circumstances, to try the effects of the
+Lunar Caustic in the treatment of Wounds and Ulcers, and having great
+reason, from these trials, to think that this remedy may be used with
+much advantage far more extensively than has hitherto been done, I lay
+the results of my experience before my medical brethren.
+
+A very natural mode of healing certain wounds and ulcers, is by
+scabbing; but this mode of treatment is attended by many
+disadvantages, as will be pointed out shortly; yet it may be supposed
+to have suggested to me some of those trials of the treatment by
+eschar, which I am about to detail.
+
+
+I. ON THE ADHERENT ESCHAR.
+
+It appears scarcely necessary to describe the immediate and well known
+effects of the application of the lunar caustic to the surface of a
+wound or ulcer. It may, however, be shortly observed that the contact
+of the caustic induces, at first, a white film or eschar which, when
+exposed to the air, assumes in a few hours a darker colour, and at a
+later period, becomes black; as the eschar undergoes these changes of
+colour it gradually becomes harder and resembles a bit of sticking
+plaster; in the course of a few days, according to the size and state
+of the wound, the eschar becomes corrugated and begins to separate at
+its edges, and at length peels off altogether, leaving the surface of
+the sore underneath, in a healed state.
+
+In the formation of this eschar several things require particular
+attention. The application of the caustic should be made over the
+whole surface of the sore; and indeed no part requires so much
+attention as the edges; to make a firmer eschar the caustic should
+even be applied beyond the edge of the wound, upon the surrounding
+skin, for the eschar in drying is apt to contract a little, and in
+this manner may leave a space between its edges and that of the
+adjacent healthy skin.
+
+At the same time, much attention must be paid to the degree in which
+the caustic is applied. In cases of recent wounds unattended by
+inflammation, it may be applied freely; but when inflammation has come
+on, too severe an application of the caustic induces vesication of the
+surrounding skin, and the edges of the eschar may in this manner also
+be loosened and removed. If every part is touched, a slight
+application of the caustic is generally sufficient.
+
+The importance of avoiding all causes which might detach the edges of
+the eschar will be apprehended by the following interesting
+observation, which I have been enabled to deduce from very extensive
+trials of the caustic; it is, that, in every instance in which the
+eschar remains adherent from the first application, the wound or ulcer
+over which it is formed, invariably heals.
+
+Not only the cause just mentioned, but every other by which the eschar
+might be disturbed, must, therefore, be carefully avoided; and
+especially, as the eschar begins to separate from the healed edges of
+the sore, it should be carefully removed by a pair of scissors.
+
+To the surface of the wound the eschar supplies a complete protection
+and defence, and allows the healing process to go on underneath
+uninterruptedly and undisturbed. It renders all applications, such as
+plasters, totally unnecessary, as well as the repeated dressings to
+which recourse is usually had in such cases; and it at once removes
+the soreness necessarily attendant on an ulcerated surface being
+exposed to the open air. In many cases too, in which the patients are
+usually rendered incapable of following their wonted avocations, this
+mode of treatment saves them from an inconvenience, which is, to some,
+of no trifling nature.
+
+It has already been stated how important it is that the eschar should
+be preserved adherent. To secure this still more effectually, I have
+found it of great utility to protect it by a portion of gold-beater's
+skin. The skin surrounding the wound is simply moistened with a drop
+of water, and the gold-beater's skin is then to be applied over it and
+over the eschar, to which it soon adheres firmly, but from which it
+may be removed at any time, by again moistening it for a moment with
+water; the same bit of gold-beater's skin admits of being again and
+again reapplied in the same manner.
+
+The other circumstances which render the eschar unadherent will be
+mentioned hereafter. In the mean time the fact stated p. 6, will
+sufficiently establish the propriety of treating distinctly of the
+adherent eschar.
+
+I now proceed to mention some other effects of the application of the
+caustic. The first is that, in cases in which there would be much and
+long continued irritability and pain, as in superficial wounds along
+the shin, all this suffering, and its consequences in disabling the
+patient, are completely avoided. A blush of inflammation forms around
+the eschar, but this gradually subsides without any disagreeable
+consequences, and the inflammation which would otherwise have been set
+up is entirely prevented by the due formation of the eschar.
+
+If inflammation be previously established, it is increased, at first,
+by the application of the caustic. But if this inflammation be not
+severe, and if the eschar remain adherent, all inflammation, both that
+induced by the application of the caustic, and that existing
+previously, entirely subsides. When the previous inflammation round
+the ulcer is considerable, however, the application of the caustic
+would induce vesication, and it should in such a case of course be
+avoided, and another mode of treatment to be described hereafter must
+be adopted.
+
+I would introduce in this place some observations on the comparative
+effects of healing by eschar and by scabbing. On the subject of
+scabbing I must refer my reader to the well known work of Mr. John
+Hunter. The advantage of healing by eschar over that by scabbing is
+quite decided. By comparative trials, I have found that whilst the
+scab is irritable and painful, and surrounded by a ring of
+inflammation, the adherent eschar is totally free from pain and
+inflammation; and that whilst the scab remains attended by
+inflammation and unhealed, the eschar is gradually separating, leaving
+the surface underneath completely healed. To these observations I may
+add that the success of the plan of healing by eschar is infinitely
+more certain as well as more speedy than that by scabbing.
+
+I shall, in conclusion, briefly recapitulate the advantages of this
+mode of treatment. In the first place, it will be found far more
+efficacious and speedy than any other; secondly, it has the great
+advantage of saving the patient much suffering and inconvenience; and
+thirdly, it renders the repeated application of dressings and
+ointments quite unnecessary. Its utility is extremely great,
+therefore, where the time of the poor, the expense of an
+establishment, and the labours of the medical officer, as well as the
+sufferings of the patient, require to be considered; and it will I
+imagine be found of no little advantage, in all these respects, in
+many cases which are incident to the soldier and sailor.
+
+
+II. ON THE UNADHERENT ESCHAR.
+
+The eschar is generally adherent in cases of recent injuries, and in
+small ulcers, when they are nearly even with the skin and attended by
+little inflammation. In other cases the eschar is too apt to be
+unadherent, and this arises from the formation of pus or of a scab
+underneath.
+
+If the eschar be unadherent by subjacent pus, it may be ascertained in
+the space of from twelve to twenty-four hours; the centre is generally
+observed to be raised and to yield to the pressure of a probe;
+sometimes the subjacent fluid has partly escaped by an opening at the
+side of the eschar.
+
+When a scab forms underneath the eschar, which does not happen except
+the fluid has been allowed to remain too long under the eschar without
+being evacuated, there are pain and some inflammation, the eschar does
+not separate, but remains long over the sore, and there is no
+appearance of healing.
+
+When it is ascertained that there is fluid underneath the eschar, a
+slight puncture is to be made by the point of a penknife, the fluid is
+to be gently pressed out, and the caustic is then to be applied to
+the orifice thus made. The same plan is to be adopted if the fluid
+ooze out at the edge of the eschar; it is to be fully evacuated by
+pressure, and the orifice is to be touched with the caustic. The
+healing process goes on best however when the orifice is in the centre
+of the eschar. After this treatment the eschar occasionally remains
+adherent, but more frequently the fluid requires to be evacuated
+repeatedly, and this should be done every twelve hours, or once a day,
+according to the quantity of fluid formed, taking care that the eschar
+be not needlessly separated by allowing the fluid to accumulate
+underneath. If, from accident, the eschar is separated before the sore
+be healed I would reapply the caustic. At length the eschar becomes
+adherent, and in due time begins to peel off, leaving the surface
+healed.
+
+In every case in which the eschar does not separate favourably, I
+begin to suspect the formation of a scab underneath, in which case the
+whole must be removed by the application of a cold poultice for two or
+three days; this has not only the effect of removing the eschar but of
+allaying any inflammation or irritation; afterwards the caustic must
+be reapplied as before.
+
+The gold-beater's skin is more useful as a protection to the
+unadherent than to the adherent eschar, as the former would be more
+liable to be torn off by accident than the latter. The gold-beater's
+skin must be removed in the manner already described, whenever the
+subjacent fluid is to be evacuated, and must be reapplied after
+touching the orifice with caustic.
+
+The pain experienced on the application of the caustic is greater or
+less according to the sensibility and size of the wound. In small
+wounds it is trifling, and of short duration; it is more severe in
+recent wounds than in ulcers; it soon subsides in every case, and
+then the patient enjoys greater ease than would be experienced under
+any other mode of treatment. Little or no pain is caused on applying
+the caustic after evacuating the subjacent fluid of an unadherent
+eschar. Altogether the pain inflicted by the caustic is far less than
+is generally imagined, and forms scarcely an obstacle to its
+employment.
+
+It may be proper, in this place, to notice such circumstances as
+render the employment of the caustic improper or inefficient. It is
+improper to employ the caustic when the ulcer is too large to admit of
+the formation of a complete eschar; or when it is so situated as to
+render it impossible that the eschar should remain undisturbed, as
+between the toes, unless, indeed, the patient be confined to his
+bed;--or in cases attended by much inflammation, or by much oedema.
+
+I have found no kind of caustic so manageable as the lunar caustic;
+and this is best applied in the solid form. I have thought too, that
+the newly prepared lunar caustic is more apt to dissolve on being
+applied than that which has been longer made and more exposed to the
+air; the latter is therefore to be preferred.
+
+
+III. ON THE TREATMENT BY ESCHAR AND POULTICE.
+
+In many cases in which it is impossible to adopt either the mode of
+treatment by the adherent or the unadherent eschar, it is of great
+utility to apply the caustic first and then a cold poultice made
+without lard or oil: this plan is particularly useful in cases of
+punctured wounds attended by much pain and swelling, and in cases of
+recently opened abscesses. By this application the pain and swelling
+are much subdued and a free issue is secured for the secreted fluid;
+and in no case have I seen the original inflammation increased by it.
+
+It is generally necessary to repeat the application of the caustic
+every second or third day, or every day if the inflammation and
+swelling of the part be considerable, and the cold poultice may be
+renewed about every eight hours. At length, however, the inflammation
+having subsided, the attempt may be made to form an adherent eschar.
+
+I have seen many cases, in which, by this mode of treatment, much
+suffering and perhaps the loss of some of the smaller joints have been
+prevented, particularly cases of deep seated inflammation of the
+fingers, which, having been neglected, have issued in severe
+inflammation, abscess, and terrible fungous growths. In these cases it
+is not only necessary to apply the caustic to the surface of the sore,
+but in every cavity or orifice which may be formed by the disease.
+
+
+
+
+CHAPTER II.
+
+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.
+
+
+
+
+CHAPTER III.
+
+OF SOME CASES IN WHICH THE CAUSTIC IS INAPPLICABLE.
+
+
+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 in which 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 ulcerated
+surface 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.
+
+
+CASE XXXIII.
+
+A little girl, aged 10, scalded her breast a week ago and has treated
+it with 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.
+
+
+CASE XXXIV.
+
+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
+of three 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 oedema 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 rather less 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 then became adherent, and in
+about a fortnight it separated, leaving the ulcer healed.
+
+
+CASE XXXV.
+
+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 in diameter 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
+centre but 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 a detached 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.
+
+
+CASE XXXVI.
+
+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 the
+legs 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 local applications, 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 ulcers were 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.
+
+
+
+FINIS.
+
+
+
+
+T. Wheelhouse, Printer,
+Nottingham.
+
+       *       *       *       *       *
+
+    +--------------------------------------------------------+
+    | Typographical errors corrected in text:                |
+    |                                                        |
+    | Page  41: cautic replaced with caustic                 |
+    | Page  65: eurative replaced with curative              |
+    | Page 107: smuch replaced with much                     |
+    | Page 120: ANOMOLOUS replaced with ANOMALOUS            |
+    |                                                        |
+    +--------------------------------------------------------+
+
+
+
+
+
+End of the Project Gutenberg EBook of An Essay on the Application of the
+Lunar Caustic in the Cure of Certain Wounds and Ulcers, by John  Higginbottom
+
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