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diff --git a/23729-h/23729-h.htm b/23729-h/23729-h.htm new file mode 100644 index 0000000..00fb1a4 --- /dev/null +++ b/23729-h/23729-h.htm @@ -0,0 +1,2708 @@ +<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"> +<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en"> + <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> + <style type="text/css"> +/*<![CDATA[ XML blockout */ +<!-- + p { margin-top: .5em; + text-align: justify; + margin-bottom: .5em; + text-indent: 1em; + } + h1 { + text-align: center; font-family: garamond, serif; /* all headings centered */ + } + h5,h6 { + text-align: center; font-family: garamond, serif; /* all headings centered */ + } + h2 { + text-align: center; font-family: garamond, serif; /* centered and coloured */ + } + h3 { + text-align: center; font-family: garamond, serif; /* centered and coloured */ + } + h4 { + text-align: center; font-family: garamond, serif; /* all headings centered */ + } + hr { width: 33%; + margin-top: 1em; + margin-bottom: 1em; + } + body{margin-left: 20%; + margin-right: 20%; + } + a {text-decoration: none} /* no lines under links */ + div.centered {text-align: center;} /* work around for IE centering with CSS problem part 1 */ + div.centered table {margin-left: auto; margin-right: auto; text-align: left;} /* work around for IE centering with CSS problem part 2 */ + + .cen {text-align: center; text-indent: 0em;} /* centering paragraphs */ + .sc {font-variant: small-caps;} /* small caps */ + .noin {text-indent: 0em;} /* no indenting */ + .block {margin-left: 5%; margin-right: 5%;} /* block indent */ + .right {text-align: right; padding-right: 2em;} /* right aligning paragraphs */ + .totoc {position: absolute; right: 2%; font-size: 75%; text-align: right;} /* Table of contents anchor */ + .tdr {text-align: right; vertical-align: top; padding-right: .5em;} /* right align cell */ + .tdl {text-align: left;} /* left align cell */ + .tr {margin-left: 15%; margin-right: 15%; margin-top: 5%; margin-bottom: 5%; padding: 1em; background-color: #f6f2f2; color: black; border: dotted black 1px;} /* transcriber's notes */ + + .pagenum { /* uncomment the next line for invisible page numbers */ + /* visibility: hidden; */ + position: absolute; right: 2%; + font-size: 75%; + color: silver; + background-color: inherit; + text-align: right; + text-indent: 0em; + font-style: normal; + font-weight: normal; + font-variant: normal;} /* page numbers */ + + // --> + /* XML end ]]>*/ + </style> + </head> +<body> + + +<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>&c. &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 phlegmasiæ?</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"> </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, &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"> </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;—or in cases attended by +much inflammation, or by much œdema.</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, &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.</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, &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,—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.</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.—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.—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.—A similar report was made on the succeeding day.</p> + +<p>On the 20th the slough was separating. The caustic and +cataplasm were applied.—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.—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—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, <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.—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.—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.—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 œdema +of the leg to which he is subject, and much pain and +inflammation of the ulcers. I directed the application of a +cold poultice and lotion, and prescribed the pil. hydrarg. +every second night with an aperient draught the following +morning.</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 œdema. 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 œdema, 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 œdema 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,—apply the +poultice,—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, &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, &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, &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 œdema towards the toes. In such a +case I should now recommend a cold poultice to be applied +for several days; but the present case occurring early in my +trials of the caustic, the latter remedy was applied +forthwith over both the ulcer and slough.</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 41: cautic replaced with caustic<br /> +Page 65: eurative replaced with curative<br /> +Page 107: smuch replaced with much<br /> +Page 120: 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 + +*** END OF THIS PROJECT GUTENBERG EBOOK LUNAR CAUSTIC *** + +***** This file should be named 23729-h.htm or 23729-h.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/2/3/7/2/23729/ + +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.) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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