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diff --git a/23729.txt b/23729.txt new file mode 100644 index 0000000..1e2454f --- /dev/null +++ b/23729.txt @@ -0,0 +1,2261 @@ +The Project Gutenberg EBook of An Essay on the Application of the Lunar +Caustic in the Cure of Certain Wounds and Ulcers, by John Higginbottom + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: An Essay on the Application of the Lunar Caustic in the Cure of Certain Wounds and Ulcers + +Author: John Higginbottom + +Release Date: December 4, 2007 [EBook #23729] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK LUNAR CAUSTIC *** + + + + +Produced by Bryan Ness, Jeannie Howse and the Online +Distributed Proofreading Team at http://www.pgdp.net (This +book was produced from scanned images of public domain +material from the Google Print project.) + + + + + + + * * * * * + + +--------------------------------------------------------+ + | Transcriber's Note: | + | | + | Inconsistent hyphenation and archaic spelling in | + | the original document has been preserved. | + | | + | Obvious typographical errors have been corrected. | + | For a complete list, please see the end of this | + | document. | + | | + +--------------------------------------------------------+ + + * * * * * + + + +ON THE + +LUNAR CAUSTIC. + + + + +AN +ESSAY +ON THE +APPLICATION +OF +THE LUNAR CAUSTIC, +IN THE +_CURE OF CERTAIN_ +WOUNDS AND ULCERS. + +BY +JOHN HIGGINBOTTOM, +_NOTTINGHAM_, +MEMBER OF THE ROYAL COLLEGE OF SURGEONS +OF LONDON. + +LONDON: +PRINTED FOR +LONGMAN, REES, ORME, BROWN, AND GREEN, +_PATER-NOSTER ROW_. +1826. + + + + +T. WHEELHOUSE, PRINTER, NOTTINGHAM. + + + + +TO +MY BROTHER-IN-LAW, + +MARSHALL HALL, M.D. F.R.S.E. + +&c. &c. +THIS LITTLE WORK IS INSCRIBED +WITH +GREAT AFFECTION. + +_Nottingham, Jan. 6, 1826._ + + + + +PREFACE. + + +The following pages are presented to the medical public with very +humble pretensions. It is chiefly with the minor accidents or diseases +that they have to do; but I shall not consider that I have laboured in +vain, if I am enabled to mitigate even these little evils of human +life. + +In these prefatory observations, however, I would suggest the question +whether the caustic may not be employed with benefit even in some of +the severer diseases to which the human frame is liable. Indeed I +consider the investigation as only just begun, and many other uses of +the lunar caustic, besides those detailed in the following pages, have +suggested themselves to me. + +May not the caustic, for instance, be of greater efficacy, because of +greater power and of quicker operation, than ordinary blisters, in +some internal diseases? + +It is repeatedly stated hereafter, that the application of the lunar +caustic is a means, in certain circumstances, of subduing external +inflammation. Might it not, on this principle, be of service in the +treatment of some of the internal phlegmasiae? + +It may be observed, that the lunar caustic may be regarded, almost +without further trial, as an effectual preventive of those cases of +irritative fever which arise from local injuries, and probably of the +effects of poisoned wounds in general. I would not, however, in the +latter cases, fail to render "sure doubly sure" by free excision. + +Might not an adherent eschar be easily formed in those cases of +compound fracture in which the external wound is of moderate size, so +as effectually to exclude the external air and prevent cutaneous +inflammation, and in more respects than one, to reduce the case to the +state of a simple fracture? This object, if attained, would be +important indeed, and I hope the suggestion will be submitted to the +most assiduous and cautious trial. + +I can have no doubt that the use of the lunar caustic admits of being +still further extended; and, as I intend to pursue the inquiry, I hope +at some future period to publish something more worthy of the +attention of the medical public. In the mean time, the plans hereafter +suggested must not be adopted without that degree of care, attention, +and perseverance, which are obviously necessary to render them +successful. + + + + +CONTENTS. + + +CHAPTER I. + PAGE +ON HEALING BY ESCHAR 1 + + I. _Of the Adherent Eschar_ 3 + II. _Of the Unadherent Eschar_ 14 +III. _On the Treatment by Eschar and Poultice_ 21 + + +CHAPTER II. + +OF THE APPLICATION OF THESE MODES OF TREATMENT TO +DIFFERENT CASES 24 + + I. _Of Punctures, Bites, &c_ 24 + II. _Of Bruised Wounds_ 64 +III. _Of Ulcers_ 82 + IV. _Of some Anomalous cases_ 120 + + +CHAPTER III. + +OF SOME CASES IN WHICH THE CAUSTIC IS INAPPLICABLE 130 + + + + +CHAPTER I. + +ON HEALING BY ESCHAR. + + +Having been led, by several circumstances, to try the effects of the +Lunar Caustic in the treatment of Wounds and Ulcers, and having great +reason, from these trials, to think that this remedy may be used with +much advantage far more extensively than has hitherto been done, I lay +the results of my experience before my medical brethren. + +A very natural mode of healing certain wounds and ulcers, is by +scabbing; but this mode of treatment is attended by many +disadvantages, as will be pointed out shortly; yet it may be supposed +to have suggested to me some of those trials of the treatment by +eschar, which I am about to detail. + + +I. ON THE ADHERENT ESCHAR. + +It appears scarcely necessary to describe the immediate and well known +effects of the application of the lunar caustic to the surface of a +wound or ulcer. It may, however, be shortly observed that the contact +of the caustic induces, at first, a white film or eschar which, when +exposed to the air, assumes in a few hours a darker colour, and at a +later period, becomes black; as the eschar undergoes these changes of +colour it gradually becomes harder and resembles a bit of sticking +plaster; in the course of a few days, according to the size and state +of the wound, the eschar becomes corrugated and begins to separate at +its edges, and at length peels off altogether, leaving the surface of +the sore underneath, in a healed state. + +In the formation of this eschar several things require particular +attention. The application of the caustic should be made over the +whole surface of the sore; and indeed no part requires so much +attention as the edges; to make a firmer eschar the caustic should +even be applied beyond the edge of the wound, upon the surrounding +skin, for the eschar in drying is apt to contract a little, and in +this manner may leave a space between its edges and that of the +adjacent healthy skin. + +At the same time, much attention must be paid to the degree in which +the caustic is applied. In cases of recent wounds unattended by +inflammation, it may be applied freely; but when inflammation has come +on, too severe an application of the caustic induces vesication of the +surrounding skin, and the edges of the eschar may in this manner also +be loosened and removed. If every part is touched, a slight +application of the caustic is generally sufficient. + +The importance of avoiding all causes which might detach the edges of +the eschar will be apprehended by the following interesting +observation, which I have been enabled to deduce from very extensive +trials of the caustic; it is, that, in every instance in which the +eschar remains adherent from the first application, the wound or ulcer +over which it is formed, invariably heals. + +Not only the cause just mentioned, but every other by which the eschar +might be disturbed, must, therefore, be carefully avoided; and +especially, as the eschar begins to separate from the healed edges of +the sore, it should be carefully removed by a pair of scissors. + +To the surface of the wound the eschar supplies a complete protection +and defence, and allows the healing process to go on underneath +uninterruptedly and undisturbed. It renders all applications, such as +plasters, totally unnecessary, as well as the repeated dressings to +which recourse is usually had in such cases; and it at once removes +the soreness necessarily attendant on an ulcerated surface being +exposed to the open air. In many cases too, in which the patients are +usually rendered incapable of following their wonted avocations, this +mode of treatment saves them from an inconvenience, which is, to some, +of no trifling nature. + +It has already been stated how important it is that the eschar should +be preserved adherent. To secure this still more effectually, I have +found it of great utility to protect it by a portion of gold-beater's +skin. The skin surrounding the wound is simply moistened with a drop +of water, and the gold-beater's skin is then to be applied over it and +over the eschar, to which it soon adheres firmly, but from which it +may be removed at any time, by again moistening it for a moment with +water; the same bit of gold-beater's skin admits of being again and +again reapplied in the same manner. + +The other circumstances which render the eschar unadherent will be +mentioned hereafter. In the mean time the fact stated p. 6, will +sufficiently establish the propriety of treating distinctly of the +adherent eschar. + +I now proceed to mention some other effects of the application of the +caustic. The first is that, in cases in which there would be much and +long continued irritability and pain, as in superficial wounds along +the shin, all this suffering, and its consequences in disabling the +patient, are completely avoided. A blush of inflammation forms around +the eschar, but this gradually subsides without any disagreeable +consequences, and the inflammation which would otherwise have been set +up is entirely prevented by the due formation of the eschar. + +If inflammation be previously established, it is increased, at first, +by the application of the caustic. But if this inflammation be not +severe, and if the eschar remain adherent, all inflammation, both that +induced by the application of the caustic, and that existing +previously, entirely subsides. When the previous inflammation round +the ulcer is considerable, however, the application of the caustic +would induce vesication, and it should in such a case of course be +avoided, and another mode of treatment to be described hereafter must +be adopted. + +I would introduce in this place some observations on the comparative +effects of healing by eschar and by scabbing. On the subject of +scabbing I must refer my reader to the well known work of Mr. John +Hunter. The advantage of healing by eschar over that by scabbing is +quite decided. By comparative trials, I have found that whilst the +scab is irritable and painful, and surrounded by a ring of +inflammation, the adherent eschar is totally free from pain and +inflammation; and that whilst the scab remains attended by +inflammation and unhealed, the eschar is gradually separating, leaving +the surface underneath completely healed. To these observations I may +add that the success of the plan of healing by eschar is infinitely +more certain as well as more speedy than that by scabbing. + +I shall, in conclusion, briefly recapitulate the advantages of this +mode of treatment. In the first place, it will be found far more +efficacious and speedy than any other; secondly, it has the great +advantage of saving the patient much suffering and inconvenience; and +thirdly, it renders the repeated application of dressings and +ointments quite unnecessary. Its utility is extremely great, +therefore, where the time of the poor, the expense of an +establishment, and the labours of the medical officer, as well as the +sufferings of the patient, require to be considered; and it will I +imagine be found of no little advantage, in all these respects, in +many cases which are incident to the soldier and sailor. + + +II. ON THE UNADHERENT ESCHAR. + +The eschar is generally adherent in cases of recent injuries, and in +small ulcers, when they are nearly even with the skin and attended by +little inflammation. In other cases the eschar is too apt to be +unadherent, and this arises from the formation of pus or of a scab +underneath. + +If the eschar be unadherent by subjacent pus, it may be ascertained in +the space of from twelve to twenty-four hours; the centre is generally +observed to be raised and to yield to the pressure of a probe; +sometimes the subjacent fluid has partly escaped by an opening at the +side of the eschar. + +When a scab forms underneath the eschar, which does not happen except +the fluid has been allowed to remain too long under the eschar without +being evacuated, there are pain and some inflammation, the eschar does +not separate, but remains long over the sore, and there is no +appearance of healing. + +When it is ascertained that there is fluid underneath the eschar, a +slight puncture is to be made by the point of a penknife, the fluid is +to be gently pressed out, and the caustic is then to be applied to +the orifice thus made. The same plan is to be adopted if the fluid +ooze out at the edge of the eschar; it is to be fully evacuated by +pressure, and the orifice is to be touched with the caustic. The +healing process goes on best however when the orifice is in the centre +of the eschar. After this treatment the eschar occasionally remains +adherent, but more frequently the fluid requires to be evacuated +repeatedly, and this should be done every twelve hours, or once a day, +according to the quantity of fluid formed, taking care that the eschar +be not needlessly separated by allowing the fluid to accumulate +underneath. If, from accident, the eschar is separated before the sore +be healed I would reapply the caustic. At length the eschar becomes +adherent, and in due time begins to peel off, leaving the surface +healed. + +In every case in which the eschar does not separate favourably, I +begin to suspect the formation of a scab underneath, in which case the +whole must be removed by the application of a cold poultice for two or +three days; this has not only the effect of removing the eschar but of +allaying any inflammation or irritation; afterwards the caustic must +be reapplied as before. + +The gold-beater's skin is more useful as a protection to the +unadherent than to the adherent eschar, as the former would be more +liable to be torn off by accident than the latter. The gold-beater's +skin must be removed in the manner already described, whenever the +subjacent fluid is to be evacuated, and must be reapplied after +touching the orifice with caustic. + +The pain experienced on the application of the caustic is greater or +less according to the sensibility and size of the wound. In small +wounds it is trifling, and of short duration; it is more severe in +recent wounds than in ulcers; it soon subsides in every case, and +then the patient enjoys greater ease than would be experienced under +any other mode of treatment. Little or no pain is caused on applying +the caustic after evacuating the subjacent fluid of an unadherent +eschar. Altogether the pain inflicted by the caustic is far less than +is generally imagined, and forms scarcely an obstacle to its +employment. + +It may be proper, in this place, to notice such circumstances as +render the employment of the caustic improper or inefficient. It is +improper to employ the caustic when the ulcer is too large to admit of +the formation of a complete eschar; or when it is so situated as to +render it impossible that the eschar should remain undisturbed, as +between the toes, unless, indeed, the patient be confined to his +bed;--or in cases attended by much inflammation, or by much oedema. + +I have found no kind of caustic so manageable as the lunar caustic; +and this is best applied in the solid form. I have thought too, that +the newly prepared lunar caustic is more apt to dissolve on being +applied than that which has been longer made and more exposed to the +air; the latter is therefore to be preferred. + + +III. ON THE TREATMENT BY ESCHAR AND POULTICE. + +In many cases in which it is impossible to adopt either the mode of +treatment by the adherent or the unadherent eschar, it is of great +utility to apply the caustic first and then a cold poultice made +without lard or oil: this plan is particularly useful in cases of +punctured wounds attended by much pain and swelling, and in cases of +recently opened abscesses. By this application the pain and swelling +are much subdued and a free issue is secured for the secreted fluid; +and in no case have I seen the original inflammation increased by it. + +It is generally necessary to repeat the application of the caustic +every second or third day, or every day if the inflammation and +swelling of the part be considerable, and the cold poultice may be +renewed about every eight hours. At length, however, the inflammation +having subsided, the attempt may be made to form an adherent eschar. + +I have seen many cases, in which, by this mode of treatment, much +suffering and perhaps the loss of some of the smaller joints have been +prevented, particularly cases of deep seated inflammation of the +fingers, which, having been neglected, have issued in severe +inflammation, abscess, and terrible fungous growths. In these cases it +is not only necessary to apply the caustic to the surface of the sore, +but in every cavity or orifice which may be formed by the disease. + + + + +CHAPTER II. + +ON THE APPLICATION OF THESE MODES OF TREATMENT TO PARTICULAR CASES. + + +I. OF PUNCTURES ETC. + +In cases of recent punctured wounds the orifice and surrounding skin +should be moistened with a drop of water; the caustic should then be +applied within the puncture until a little pain be felt, and then over +the surrounding skin, and the eschar must be allowed to dry. In this +manner it is astonishing how completely the terrible effects of a +punctured wound are prevented; the eschar usually remains adherent, +and the case requires no further attention. + +At a later period after the accident, when the caustic has been +neglected, some degree of inflammation is usually present, the orifice +is nearly closed with the swelling, and a little pus or fluid is +formed within. A slight pressure will evacuate this fluid, the caustic +may then be applied within the puncture, and over the surrounding +skin, beyond the inflammation, and must be allowed to dry. In this +manner we frequently succeed in forming an adherent eschar, and all +inflammation subsides. Any slight vesication which may be raised +around punctured wounds is not of the same consequence as when an +adherent eschar is wished to be formed over a sore or ulcer; one or +more small punctures may be made to evacuate the fluid and the part +may be allowed to dry. + +If there is reason to think that an abscess has actually formed under +the puncture to any extent, it must be opened freely by a lancet and +treated with caustic and poultice, keeping the poultice moist and cold +with water. + +In cases of puncture where the orifice is healed and where an +erysipelatous inflammation is spreading, attended with swelling, I +have applied the caustic freely over and beyond the inflamed parts, +and I have had the satisfaction to find that the inflammation has been +arrested in its progress and has shortly subsided. + +This mode of treatment is particularly useful in cases of punctured +and lacerated wounds from various instruments, such as needles, nails, +hooks, bayonets, saws, &c. and in the bites of animals, leech-bites, +stings of insects, &c. In considerable lacerations the same objection +would exist to this treatment as in large ulcers. + +The dreadful effects of punctures from needles, scratches from bone, +or other injuries received in dissection, are totally prevented by +this treatment. I have for the last five years had frequent +opportunities of trying it in these cases and have the most perfect +confidence in its success. + +The advantage of these modes of treating punctured wounds will however +be best explained and established by a selection of cases, to which I +can add particular remarks as they may be suggested by peculiarities +in the cases themselves. + + +CASE I. + +A.B. received a severe punctured wound by a hook of the size of a +crow-quill, which pierced into the flesh between the thumb and +fore-finger on the outside of the hand; scarcely a drop of blood +followed, but there was immediately severe pain and tumefaction. The +lunar caustic was applied without loss of time, deep within the +orifice and around the edge of the wound; and the eschar was left to +dry. The smarting pain induced by the caustic was severe for a time +but gradually subsided. + +On the ensuing day, the eschar was adherent and there was little pain; +but there was more swelling than usual after the prompt application of +the caustic, owing to the mobility of the part. + +On the third day the swelling remained as before, and there was a +little sense of heat. On the fourth day the swelling and heat had +subsided, and the eschar remained adherent. On the succeeding day the +eschar had been removed by washing the hand, and the puncture was +unhealed but free from pain and irritation. The caustic was +reapplied. + +From this time the eschar remained adherent, and at length gradually +separated leaving the part perfectly well. + +It is quite certain that under any other mode of treatment this severe +puncture would have greatly inflamed and have proved very painful and +troublesome; and it is not improbable but that suppuration and much +suffering might have ensued. All this is effectually and almost +certainly prevented if the caustic be applied promptly, as in this +case. When time has been lost, the case is very different as will +appear hereafter; but even in these cases, the caustic proves an +invaluable application. + + +CASE II. + +Mrs. Middleton, aged 40, wounded her wrist, on the ulnar side, by the +hook of a door post; there was a considerable flow of blood at first, +but this ceased suddenly and the arm immediately became affected with +great pain and swelling. The lunar caustic was applied in half an hour +after the accident. + +On the following day the eschar was observed to be adherent, and the +patient reported that she had suffered scarcely any pain, after the +smarting of the caustic had ceased. There was a slight swelling round +the puncture but that of the arm had totally subsided. The caustic was +applied over and beyond the swelling. On the third day all tumefaction +had subsided and there was no complaint whatever. + +I hoped that this case would have required no further attention or +remedy. But my patient contrived unfortunately to rub off the eschar +about a week after its formation, and so to expose the subjacent wound +unhealed; she suffered however no pain or inconvenience from it; and +it was again shielded by means of a fresh eschar, which remained +adherent until removed by the healing process underneath. + +This puncture was so severe that the arm was in a state of ecchymosis +for six or eight inches upwards, and I doubt not that without the +caustic, there would have been severe and long continued suffering, +and perhaps painful suppurations. + + +CASE III. + +A female servant punctured the end of the finger by a pin; there +succeeded much pain and swelling, and it appeared that the nail would +separate, and the cuticle all round the finger was raised by the +effusion of fluid. This fluid was evacuated and a poultice applied. + +On the third day the cuticle was removed, and the exposed surface was +found to be ulcerated in several spots. The lunar caustic was passed +slightly over the excoriated surface, which was then left exposed to +dry. + +On the succeeding day the eschar was adherent and the pain had almost +subsided. On the next day, the eschar still remained adherent, and as +there was neither pain nor soreness, the patient used her finger. + +The eschar was at length removed by the healing process and was +separated together with the nail, and the case was unattended by any +further inconvenience or trouble either to the patient or myself. + +It is scarcely necessary to contrast the advantage of this mode of +treatment with that by plasters, poultices, &c. It is at once more +speedy and secure, and less cumbersome to such patients as are obliged +to continue domestic avocations. + + +CASE IV. + +The present case is somewhat more severe than those which have been +already given, and what is of great importance, the caustic was not +applied immediately after the accident. + +William Chantry, aged 50, received a stab in the wrist with a hay-fork +yesterday and applied a poultice; to-day there are great pain and +swelling, and the wounded orifice is very small. I applied the lunar +caustic within the puncture, and directly a cold poultice to be worn +over it; the arm was kept in a sling. + +The next day the swelling and pain were diminished, and a little lymph +flowed from the wound. I again applied the caustic and continued the +poultice. + +Two days afterwards, the swelling and pain were nearly gone. The +poultice was merely continued, the caustic not being requisite from +the subsidence of the inflammation. The patient came to me again in +four days more quite free from pain and swelling. The poultice was +discontinued, and the caustic was then applied in order to form an +adherent eschar, in which I was successful. + +This case illustrates many important points; 1. it shows the efficacy +of the caustic with the poultice as a remedy against inflammation; 2. +it presents an instance of a labouring man returning to work on the +sixth or seventh day after a severe accident, even when the +application of the caustic had been unfortunately delayed; 3. it +points out the proper treatment, when all hope of the treatment from +the first by adherent eschar is lost from such delay,--for had this +been attempted in this case, suppuration would doubtless have taken +place from the closed state of the puncture by the swelling;--our +objects must therefore be, to open the puncture and to subdue the +inflammation, and these objects are admirably attained by means of the +caustic. + +The following case is not less instructive. + + +CASE V. + +Mr. Cocking's son, aged 12, received a stab in the palm of the hand +from a penknife three days ago, which has been followed by much +swelling and pain, the punctured orifice being nearly closed. I +applied the lunar caustic as deep as possible within the puncture and +directed a cold poultice to be laid over the whole hand. + +On the next day I found that the poultice had not been applied; there +were more pain and swelling; an eschar was formed over the puncture +which I removed and thus gave issue to a considerable quantity of +pus; I again enjoined the application of a cold poultice kept +constantly moist and cold with water. + +On the succeeding day, the inflammation had greatly subsided. I +repeated the application of the caustic and poultice. On the fourth +day the inflammation had nearly disappeared and on the fifth entirely. + +In such cases the caustic unites the advantages of at once opening the +puncture and of subduing the inflammation, thus preventing the +formation of deep-seated abscesses. + + +CASE VI. + +A little boy, aged 12, received a stab by a penknife a few days ago, +in the fore part of the thigh; there are now great pain and swelling, +the orifice is nearly closed, and he has feverishness with headach. I +applied the lunar caustic deeply in the wound, and directed a poultice +and a cold lotion to be kept upon the inflamed parts; and suspecting +fascial inflammation, I took away ten ounces of blood and administered +purgative medicine. + +On the next day, the inflammation had greatly subsided; the cataplasm +and lotion were continued. + +On the third day, there was some inflammation round the puncture which +appeared to be closing; I repeated the application of the caustic +within the orifice of the wound. + +On the fourth day the swelling was subsiding and there was no pain. +The poultice and lotion were continued.--From this time there was no +occasion for any remedy, and the little patient speedily recovered. + + +CASE VII. + +Mr. Parr, aged 30, of delicate habit, trod upon a needle which pierced +the ball of the great toe; a free crucial incision was made but the +needle could not be found; a poultice was applied to the wound and +over the poultice a cold lotion. + +In the course of a week part of the needle came away. He did not rest +as he was enjoined to do, and, in consequence, severe inflammation +came on, and in two days time, fluctuation was perceived over the +joint, opposite to the puncture; a free incision was made, and some +pus was evacuated. + +On the following day there was a free discharge, but very considerable +inflammation had taken place on the side of the ball of the toe; a +free incision was made in this part, and a fresh quantity of pus was +evacuated. + +On the succeeding day, the inflammation was somewhat abated; but on +the next day, it had again become exasperated, and the openings made +for the evacuation of matter were somewhat closed by the swelling. I +now introduced the lunar caustic very freely into these openings, and +reapplied a cold poultice and lotion. + +On the following day, I found that my patient had slept well for the +first time since the developement of inflammation, and had suffered +far less, after the smarting pain from the application of the caustic +had subsided, than before; the punctured orifices were open, and the +skin, which was extremely tense the day before, was become soft and +flexible. + +From this time, I found nothing necessary but to repeat the +application of the caustic about every third day to subdue +inflammation and to keep the wounds open, which it always effected. +The joint ever afterwards remained stiff, from which we may infer the +violence of the inflammation; and when we consider what was the +constitution of my patient, we cannot, I think, doubt that the caustic +prevented many serious events usually consequent in such cases under +the ordinary treatment. + +It is highly worthy of remark, that the good effects of the +application of the caustic, in this case, were too immediate and +distinct to be mistaken. + + +CASE VIII. + +This case illustrates the mode of treatment by the lunar caustic, of +those terrible effects of punctured wounds which have been neglected +in the beginning. + +B. Unwin, aged 40, washerwoman, applied to me on July the 10th, 1820, +with severe inflammation and ulceration of the middle finger, arising +from a puncture by a pin or needle some time before; there was much +painful tumefaction, and the integuments had burst along nearly half +of the length of the finger, on the ulnar side, and over the middle +joint on the radial side; the probe did not however pass to the bone +or into the joint. I applied the lunar caustic deep in every part, and +over the whole surface, and enveloped the finger in a cold poultice +covered with cold water. + +On the 11th she reported that she had slept well for the first time +during the last fortnight; to-day there is scarcely any pain, but she +complains of soreness; the swelling has greatly subsided. The caustic +was again applied and the poultice and lotion continued. + +On the 12th there were still swelling and pain; there was considerable +bleeding from the wound, so that I could not apply the caustic well. + +On the 13th the swelling and pain were nearly gone. I repeated the +caustic which induced bleeding from the fungous flesh. + +On the 14th the swelling had nearly subsided; the cuticle was +separating all over the finger. The lunar caustic was applied +extensively over the wound and abraded parts and induced little +bleeding or pain. + +On the 15th the fungous was nearly removed; the wound presented an +appearance of slough over its surface.--The caustic was applied to the +remaining fungous. + +On the 17th the wound was much smaller and the slough separating. The +caustic and cataplasm were applied as before.--A similar report was +made on the succeeding day. + +On the 20th the slough was separating. The caustic and cataplasm were +applied.--A similar report was made on the 22d. + +On the 24th the slough having separated the integuments over it were +flabby and loose; the caustic was applied to them. + +By a continuation of this plan the wound gradually contracted, and, at +length, when there was no further use for the cataplasm, the eschar +became adherent and the sore healed underneath. It appeared highly +probable to me that, under ordinary treatment, the finger, in this +case, would have been lost. + + * * * * * + +I shall in this place, introduce a few observations on wounds received +during dissection. + +It is not in my power to give any cases in illustration of the +treatment of the severer accidents resulting from these wounds; for +since I began the free use of the lunar caustic all the terrible +effects of such wounds have been invariably prevented. + +I may here mention that in the years 1813 and 1819, respectively, I +was myself exposed to great danger from inoculation during the +examination of dead bodies. Since the latter period I have repeatedly +been exposed to the same danger from inoculation, but in every +instance, the danger has been completely averted by the prompt and +free application of the lunar caustic. + +The following is the exact mode of treatment which I would adopt in +such cases. + +In recent punctures the caustic should be applied in the manner +already described in cases of simple punctured wounds. + +When the case has been neglected, a small tumour is usually formed +underneath the skin with smart stinging pain; this tumour should be +removed entirely by the lancet, and the caustic should be applied, +both to the surface of the wound and over the surrounding skin, to +form an adherent eschar. + +When the case has been still longer neglected, and inflammation of the +absorbents has supervened, a free crucial incision is to be made, the +caustic is to be very freely applied, and afterwards a cold poultice +and lotion, the usual constitutional remedies being actively enforced. + + * * * * * + +In connexion with punctured wounds I here subjoin several cases of the +bites of animals. + + +CASE IX. + +James Joynes, aged 12, was bitten by an ass, on each side of the +middle finger; the wounds were severe, and almost immediately +followed by swelling and great pain. The lunar caustic was well +applied within half an hour after the accident. + +On the succeeding day, the eschar was found to be quite adherent, and +the pain and swelling had subsided. + +The eschar separated in about twelve days and the wounds were healed. + + +CASE X. + +Mr. Worth's daughter, aged six, was thrown down by a dog and bitten +severely on the face and forehead in three places; one of the wounds +in the cheek was deep from the penetration of the dog's front teeth, +and the parts were much bruised. The lunar caustic was well applied in +half an hour after the accident to each of the wounds, and the eschar +was covered with gold-beater's skin. + +On the next day the eschars were adherent. There was some swelling +from the severity of the bruise; but the child made little complaint. + +On the third day, the swelling remained as before and the eschar +adherent. On the fourth, the swelling had nearly disappeared.--The +eschar separated in nine days from the infliction of the wound, +leaving the parts healed and free from scar. + + +CASE XI. + +Mrs. G. was bitten by a little dog on forefinger about a fortnight +ago. There is now a very irritable, inflamed, fungous sore. I removed +the fungous by a pair of scissors and applied the lunar caustic to +form an eschar. + +On the succeeding day, I found that the patient had applied a little +lint before the eschar was dry, which had prevented it from remaining +adherent. I reapplied the caustic and desired that the eschar might be +exposed to dry. + +The eschar remained adherent, the inflammation subsided and the case +gave no further trouble. + + +CASE XII. + +A servant maid was bitten by a dog in four places--severely on the +forearm--three days ago. Adhesive plaster had been applied. There is a +wound across the arm two inches in length and three-fourths of an inch +in breadth, attended by dull pain, and swelling of the arm. I applied +the caustic to form an eschar, covering it with goldbeater's skin. + +On the following day the eschar remained adherent round the edges, but +had a puffy feel in the centre; I pierced it with a penknife and a +little bloody fluid escaped, and I touched the orifice thus made with +the caustic. The swelling remained as before, with a degree of +soreness. + +On the next day the swelling had subsided. The eschar had the same +character; a little fluid was again evacuated and the caustic applied +to the orifice as before. + +This mode of treatment was pursued for nine successive days when the +eschar remained adherent in every part. + +This patient continued her usual avocations all along. Under any other +plan of treatment I think it impossible that she should not have been +compelled to rest for a number of days. + +Adherent eschars were formed on the other three bites which were less +severe, from the first application. + +A very irritable sore sometimes forms after the application of +leeches. I knew one lady who was confined during five weeks with +several sores on her foot from such a case. I have no doubt that the +application of the caustic would have prevented all the inconvenience +and suffering she experienced. This observation will be confirmed by +the following case. + + +CASE XIII. + +Am old man applied leeches to the instep for inflammation occasioned +by a bruise. Several very irritable sores were produced with some +swelling. I applied the lunar caustic to form an eschar. + +On the following day, the eschars were adherent, the swelling had +subsided, and he had slept well for the first time of several nights. + +I do not, however, think the lunar caustic would succeed in such cases +if attended by great inflammation, without the previous application of +a cold poultice with rest for a day or two. + + +II. ON BRUISES. + +It has been already observed, p. 9, that the caustic is an invaluable +remedy in cases of bruised wounds of the shin. In these, as in all +other cases, the value of this remedy is greatly enhanced by an early +application. In bruises on the shin I have not had a single instance +in which I was not enabled to effect a cure by the adherent eschar, if +application was made to me early. The difficulty of forming an +adherent eschar is always increased by delay; but in these bruises +along the shin there is an additional reason for this increased +difficulty, arising out of the tendency observed in them, to the +formation of a slough. + +In this place I have, indeed, to make an observation of particular +interest, both in a pathological and curative point of view; it is, +that the formation of this slough has always been prevented by an +early application of the caustic, in the cases which have hitherto +fallen under my care. This fact may probably admit of explanation in +the following manner; the bruise partially destroys the organization +of the part, and the subsequent inflammation completing what the +injury had partially effected, a loss of vitality takes place, and +the slough is formed. The early application of the caustic has +already been shown to have the remarkable effect of preventing the +inflammation consequent upon certain wounds, and thus the part is +suffered to recover from the injury done to its organization, and its +vitality is preserved. + +Whether this mode of explaining the fact be correct or no, the fact +itself is extremely important, for the formation of a slough, which +the early application of the caustic can alone prevent, renders it +quite impossible to effect the formation of an adherent eschar. + +When the patient applies too late after the accident to prevent the +formation of a slough we must still treat the case by the caustic. It +is to be applied over the bruised and inflamed part. The eschar +remains adherent round the part occupied by the slough and prevents or +moderates the inflammation, and when the slough separates an eschar is +to be formed over the exposed sore. + +In the neglected and severer cases of bruise attended by much +inflammation, it will be found best to treat the part for a day or two +by a cold poultice to give time for the inflammation to subside; +otherwise the caustic might induce vesication of the skin, as I have +mentioned already, p. 5, and the eschar could not be adherent. + + +CASE XIV. + +The first case of bruise which I shall detail was not severe, but will +serve to illustrate the mode of treatment by the adherent eschar. + +Mr. Symons, aged 60, slipped off a chair and bruised the shin, last +evening; the skin was removed to the extent of an inch in one part and +a square inch in another. He applied a common poultice. During the +night he had much pain, and to-day there is much inflammation round +the wounds. I applied the lunar caustic over both wounds and covered +the eschar with gold-beater's skin to prevent the contact of the +stocking. + +On the following day the eschar was found to be perfect. The pain had +entirely ceased. There was a little vesication round one of the +wounds. I simply evacuated the fluid of the vesication and left the +part exposed to dry. + +On the third day there was no pain or inflammation, and the eschar +remained adherent. + +From this time no remedy was required. The eschar separated leaving +the surface healed, in about a month from the occurrence of the +accident. The patient suffered no sort of inconvenience nor was he +confined from his labours a single day. + + +CASE XV. + +The following case was far more severe, but the mode of treatment was +not less efficacious. + +Mr. Granger, aged 36, was exposed to a severe bruise by a great weight +of stones which had been piled up, falling upon the outside of the +leg; he was extricated from this situation with much difficulty. +Besides the bruise, the skin was removed from the outside of the leg +to the extent of ten or twelve inches in length, and in some parts an +inch and half in breadth; and in the forepart of the ankle a deep +furrow was made by the rough edge of one of the stones. I applied the +caustic in about half an hour after the accident, over the whole +surface of the wounds, and protected the eschar by the gold-beater's +skin. The patient was directed to keep the leg cool and exposed to the +air. He took no medicine. + +On the succeeding day the leg was a little swelled, but the patient +did not complain of any acute pain but only of a sense of stiffness. +An adherent and perfect eschar was found to be formed over the whole +extent of the wound. There was no fever. + +On the third day, the swelling had abated. No further remedy. The +patient was still enjoined to rest. + +On the fourth day the swelling was nearly gone. The eschar remained +adherent. The patient walks about. + +From this time the patient pursued his avocation of a stone-mason; no +further remedy was required; no inconvenience experienced; and the +eschar separated in about a month. + +I think it totally impossible to have cured this wound, by any other +remedy, in less than a month; during which period the patient must +have suffered much pain and fever, and have been quite confined. + +It is also quite certain, I think, that there would have been an +extensive slough, from the severity of the bruise. This was doubtless +prevented by the application of the caustic. + + +CASE XVI. + +J. Jennings, bricklayer, aged 26, fell through the roof of a house and +bruised and lacerated his shin rather severely to the extent of an +inch and half in one part and in several other places in a less +degree. I applied the lunar caustic to the wound immediately. + +On the following day the eschar was found to be adherent, and there +was neither pain nor swelling. + +The eschars separated in nine days leaving the wounds healed. + +It is remarkable that the eschar remains a greater or less time over +the wound according to the severity and exigency of the case. This +case being less severe than the former one the eschar remained upon +the wound during a much shorter period of time. + + +CASE XVII. + +An old man, aged 60, received a bruise upon the occiput from a fall; +the skin was lacerated and removed to the extent of half-a-crown. I +applied the lunar caustic soon after the accident. + +On the next day an adherent eschar was formed. There was neither pain +nor swelling.--The eschar separated in a fortnight. + + +CASE XVIII. + +Mrs. C. aged 40, was detained on a journey by a bruised wound on her +knee, received a fortnight before, which was healing very slowly under +the usual mode of treatment. The inflammation was subsiding but the +sore was extremely irritable and painful, and she was prevented from +moving. From the degree of inflammation still present, I applied the +lunar caustic very slightly over the sore and not over the inflamed +skin; I left the eschar to dry, but was very doubtful, from the same +cause, whether it would be adherent or no. + +On the succeeding day I found that the eschar did remain adherent and +that the inflammation was diminished, and the soreness had entirely +subsided after that induced by the caustic had ceased. + +On the next day, the lameness was gone, and there was no sort of +inconvenience from the wound. My patient continued her journey on the +following day, so that I do not know when the eschar separated. + +In regard to the inflammation attendant on these wounds, I would +remark that slight inflammation is relieved by the application of the +lunar caustic and does not prevent the formation of an adherent +eschar; but very severe inflammation requires the application of the +cold poultice and lotion over the wound, and it is necessary to watch +for the period when an eschar may be attempted with the lunar caustic. +This a little experience will readily teach. + +It is further to be particularly observed that the inflammation +attendant on a recent wound is removed by the caustic, when the same +degree of inflammation at a later period, and with suppuration, would +be aggravated and require the cold poultice and lotion, and render +the formation of an adherent eschar impossible. This fact, the result +of much experience, is extremely interesting, and, I think, not easy +to be explained. It is illustrated by the following case. + + +CASE XIX. + +Robert Hill, aged 16, received a blow yesterday from a bone which was +thrown at him, upon the outer condyle of the humerus. He complains of +extreme pain and there are much redness and swelling. I applied the +lunar caustic and directed the part to be exposed to the cold air. + +On the succeeding day, I found that the eschar was quite adherent, and +that the pain, redness and swelling had much subsided, although there +was some stiffness of the elbow. + +On the third day there was still further amendment. From this time no +remedy or attention was required. + + +CASE XX. + +It frequently occurs to surgeons to receive slight wounds upon the +hands which prove very troublesome. Of this kind is the following. + +Mr. L.C. had an irritable and inflamed sore on the ulnar side of the +third finger, occasioned by a bruise a fortnight ago. Many +applications had been made during this fortnight but the sore had no +disposition to heal. I applied the lunar caustic to form an adherent +eschar. + +From this time the pain and inflammation subsided. The eschar remained +firm and adherent, and in six days separated leaving the wound +healed. + + +III. ON ULCERS. + +From the preceding observations it would naturally be concluded that +the lunar caustic would afford a remedy for the treatment of ulcers. +This conclusion is perfectly just. Yet there are many circumstances +which render the mode of treating ulcers by the caustic, efficacious +or the contrary. + +In order that the treatment by eschar may be successful, there must be +the following conditions in regard to the ulcer: first, the surface +occupied by the ulcer must not be too extensive; secondly, it must +not be exposed to much motion or friction; and thirdly, it must not be +attended by a profuse discharge; for all these circumstances have a +direct effect in, preventing the formation of an adherent eschar or of +removing it if formed. + +I observe, therefore, that I have not found the mode of treatment by +eschar to succeed in large ulcers of the legs. But in small ulcers, +and especially in those irritable and painful little ulcers which are +so apt to form about the ankle and occasionally occur near, the tendo +achillis, and in which Mr. Baynton's plan is inadmissible, the caustic +is invaluable; in these cases the cold poultice and lotion should +precede the application of the caustic, for a few days, that the +irritability and inflammation of the sore and surrounding skin may be +first subdued; and after the eschar is formed, the part must be kept +exposed to the air and defended from external injury, by enjoining the +patient to wear trowsers and to be careful not to disturb the eschar. + +The plan of curing ulcers is exactly what has been described in the +treatment by the unadherent eschar. For in these cases the eschar is +generally unadherent at first. It is necessary therefore in all cases, +except those of very small ulcers, to examine the eschar, making a +small puncture or rather smooth incision in its centre, so as to +evacuate the subjacent fluid if there be any, taking great care not to +break down or bruise the eschar so as to leave its inferior surface at +all ragged. This operation should be repeated daily until the eschar +proves to be quite adherent. And if the ulcer be rather large, rest +should be enjoined until the adherent eschar be fully and safely +formed, and a dose of saline purgative may be interposed. It must also +be particularly borne in mind, that the eschar must be constantly +defended by the gold-beater's skin, which must be removed and +reapplied at each examination. + +I have here spoken of ulcers upon the legs. But the same observations +apply to ulcers on other parts of the body, and these are, in general, +far more manageable than the former, and do not require the same rest +during the unadherent state of the eschar. + + +CASE XXI. + +Mrs. Butcher, aged 52, has two ulcers a little above the outer ankle, +one the size of half-a-crown, the other, of a shilling, of four months +duration, which are now in a healing state by the application of +cerate and poultice; the healing process is going on very slowly. +These ulcers were caused by a fall which bruised the part but made no +wound at the time; two small spots, which she compared to the pustules +of small-pox, formed, broke, and gave rise to the ulcers. I applied +the lunar caustic to form eschars. + +At this time I had not begun to defend the eschar by the gold-beater's +skin, and in consequence both these eschars were torn by the patient's +stocking having adhered to them, and there was an oozing of fluid from +the centre of each eschar on examination on the following day. I again +applied the lunar caustic. + +On the succeeding day, I found that the large eschar had again been +disturbed, the patient having applied a little linen, instead of +leaving it exposed. I reapplied the lunar caustic. + +On the next day both eschars were complete, but there was a little +fluid under the centre of each, which required to be evacuated by an +incision. There was little inflammation or pain. + +On the following day, my patient expressed herself as astonished at +the rapid amendment. A little fluid was again evacuated from beneath +the centre of the eschar. + +On the next day the smaller eschar was quite adherent; under the large +one, there was still a very little fluid. + +About the ninth day, both the eschars were perfectly adherent. In two +days afterwards the eschars began to separate round the edges, and in +a few days more, it was necessary to remove the separating portion by +the scissors.--In the course of time the eschar separated completely, +leaving the ulcers healed. + +Mrs. Butcher had no pain after the first four days from the +application of the caustic, and in a week was able to attend to her +household affairs. + + +CASE XXII. + +J. Copeland, blacksmith, aged 38, came to me with many deep +ulcerations, from the size of a horse bean to that of a pea, attended +with great pain, heat, itching and excoriations of the surrounding +skin, obliging him to rest at different times, for several days +together. These ulcers came without any apparent cause, have continued +for many weeks, and have only been a little benefitted by rest, +although he has applied many kinds of ointment, the last consisting of +equal parts of mercurial and of the tar ointment. I applied the lunar +caustic upon each ulcer, but not over the excoriation, and I enjoined +the patient to leave the whole exposed to dry. + +On the following day, I was gratified to find that eschars had formed +upon every ulcer; upon examination, a little fluid was found to +subsist under several of the larger eschars; this I evacuated, and I +then applied the lunar caustic to the points from which it had issued +to make up the breach of continuity of the eschars over the surface of +the ulcers. There was far less inflammation and scarcely any pain, and +he has continued his occupation of blacksmith. + +On the third day nearly all the eschars were adherent; three, however, +had unfortunately been removed by an accident; I renewed them by again +applying the caustic. + +In four days after the last report, most of the eschars had separated +from the smallest ulcers leaving the parts healed. + +In a day or two more, my patient took cold and was affected with +hoarseness and cough, and the skin round the eschar became excoriated +a little. I directed a saline purgative and applied the lunar caustic +to the excoriated parts. + +On the succeeding day his cold was better and the eschars adherent. I +directed five grains of the Plummer's pill to be taken night and +morning, which he continued about a week. + +Five days after this period, I again observed a disposition to +excoriate. I applied the caustic. + +In two days more, the eschars were adherent, and there was no further +appearance of excoriation. + +In ten more days, the eschars had separated and all the ulcers and +excoriations were completely healed. + +This case occurred several years ago, and there has been no return of +the affliction whatever. + + +CASE XXIII. + +Mr. Marshall, aged 60, had a troublesome ulcer under the outer ankle, +of an oblong form and of the size of sixpence. He has been long +subject to ulcers of the legs, and he had a similar ulcer to the +present one in the same situation, some years ago, which proved +extremely difficult to heal under usual remedies. The veins are +varicose.--From the small size of the ulcer, I applied the lunar +caustic and protected the eschar by the gold-beater's skin. + +On the following day, I found the eschar complete but unadherent by +the effusion of a little fluid; this I evacuated daily in the manner +already described, for about a fortnight, when the eschar became +adherent. + +During the progress of the cure a little excoriation formed round the +eschar. I touched the parts with the caustic, and the eschar thus +formed served to support that formerly made, and so to do good. The +whole adhered until the sore was very nearly healed; but as it was +situated in a part greatly exposed, it was removed by accident. The +caustic was again applied; fluid formed underneath the eschar as +before and required evacuating thrice; but at length the eschar +adhered, and in due time separated leaving the ulcer quite healed. + +The same patient has since been affected by similar ulcers at +different times in different parts of the leg. He applied early and +they were each time easily cured by one application of the caustic. He +has also twice had injuries upon the shin, which were readily cured in +the same manner. + + +CASE XXIV. + +The following case must not be regarded as altogether trifling. For +such sores are very apt to spread and to remain long very +troublesome. + +An old gentleman came to me with an oblong ulcer on the shin about an +inch in length; it was very painful and inflamed. I applied the lunar +caustic to form an eschar and requested him to call on the following +morning. He did not come, however, but on seeing him the next day it +was requisite to evacuate a little fluid; this was repeated on they +third day, after which period the eschar remained adherent, and the +part totally free from pain. + +The eschar separated in about three weeks leaving the part healed. + + +CASE XXV. + +The following case illustrates the superior efficacy of the lunar +caustic over the ordinary modes of treatment in some ulcers of the +legs, and will, I trust, be found particularly interesting. + +Mr. G.B. aged 60, a very tall and stout person, had two ulcers, one of +the size of a shilling upon the back of the leg just above the tendo +achillis, the other rather less, on the outside of the leg; they were +caused by his scratching the parts severely three months before; and +he had used various remedies in the interval. There were some oedema +of the leg to which he is subject, and much pain and inflammation of +the ulcers. I directed the application of a cold poultice and lotion, +and prescribed the pil. hydrarg. every second night with an aperient +draught the following morning. + +This plan of treatment was continued for a number of days without any +appearance of healing in the ulcers. As the inflammation had subsided +I proposed to adopt the mode of treatment recommended by Mr. Baynton, +fearing that any attempt to heal the ulcers by eschar would fail on +account of the oedema. This project was deferred, however, by the +patient's wish to try the effect of sea-bathing. After a month's +residence on the sea shore I was, on the return of my patient, again +requested to examine these ulcers, which I found very nearly in the +same state as before, only with the addition of some excoriations. I +recommended the cold poultice for a few days to allay inflammation, +and then tried Mr. Baynton's plan, dressing the leg myself daily; on +the fourth day, however, the sore above the tendo achillis became so +irritable that I was compelled to desist and to remove the plaster and +bandage, and I again directed the cold poultice with rest, for a few +days. + +When the inflammation had again subsided, I ventured, notwithstanding +the oedema, to apply the lunar caustic to form an eschar, enjoining +rest and the horizontal position. + +On the following day complete but unadherent eschars were formed over +each sore. There, had been no pain after the smart of the caustic had +ceased. On carefully making an incision into the centre of each +eschar, a little fluid was evacuated. + +On the second day, rather more fluid was evacuated in the same manner. +There was a little more inflammation round the eschar than yesterday. + +On the third day the sores were exactly in the same state. On the +fourth, the patient having used his leg a little, rather more fluid +was evacuated from the centre, and there was rather more inflammation +round the edges, of the eschars. I enjoined the strictest rest. + +On the fifth day, there were less inflammation and discharge. + +From this day until the tenth the fluid required daily evacuation; the +eschar became adherent, and I allowed my patient to walk about. + +In about six weeks the eschar was nearly separated and I removed it +by the scissors, leaving only a portion adherent of the size of a +pea. It had been prevented from being removed from the beginning, by +the gold-beater's skin. The smaller eschar had dropped off leaving the +ulcer quite healed. In a week more the last portion of eschar +separated from the larger sore, leaving it also quite well. + + +CASE XXVI. + +The following case occurred in the person of a lady with varicose +veins and far advanced in pregnancy. Its speedy cure by the caustic +was, therefore, the more remarkable, and saved her much trouble and +suffering. + +Mrs. C. aged 40, had two small irritable and inflamed ulcers, under +the inner ankle. I applied the lunar caustic to form an eschar. + +It was requisite to evacuate a little fluid from under the eschars for +three successive days; they then remained adherent. + +About the usual time the eschars separated, leaving a small point of +the size of a pin's head, unhealed; this I again touched with the +caustic. The case required no further attention. + +This case leads me to caution my readers always to examine the parts +carefully after the separation of the eschars, and if there be the +slightest ulcer remaining to apply the caustic to it. + + +CASE XXVII. + +Mrs. Wakefield, aged 36, had an extensive ulceration with excoriation +on the upper part of the right breast, of two months continuance; it +had been greatly aggravated by improper treatment. I applied the lunar +caustic over the whole ulcerated and excoriated surface. It gave much +pain. + +On the following day I was concerned to find that part of the eschar +had been separated by the patient's dress. I repeated the application +of the caustic and again directed the part to be exposed and carefully +protected from being disturbed. The breast required to be supported +being full of milk. + +On the succeeding day an adherent eschar existed over all the +ulcerated parts, and the pain, redness, and irritation had nearly +subsided. + +On the fourth day there was still less pain and inflammation. On the +eight the eschars had separated and the breast was quite well. + + +CASE XXVIII. + +Mrs. U. aged 60, has been subject to ulcerated legs for several years. +She has one ulcer on the outer ankle of the size of a shilling, and +another behind it of the size of a horse-bean; they have been +extremely troublesome and under surgical treatment for the last year, +but during the last few weeks she has tried cerate, poultice, and the +cold lotion. The leg is much swollen and inflamed, the redness +extending several inches round the wound and over the instep; the +oedema increases towards night. She has been in the habit of taking +saline purgatives frequently. + +I directed my patient to continue the cold poultice and lotion, and to +rest completely for several days. At this period, the inflammation +having somewhat abated, I applied the lunar caustic to form eschars +and protected the parts with gold-beater's skin. + +On the following day there was a slight increase of redness round the +eschars. Upon making an incision into their centre some fluid was +evacuated. The same report was made on each of the two following +days. + +On the seventh day, the eschars having been neglected, fluid had +escaped from beneath the eschars at their edges, and my patient +complained of more pain. A little more fluid escaped in the same +manner on the following day on making a little pressure upon the +eschars. I applied the caustic to make up the breach. + +Subsequently to this day there was an increase of inflammation. From +this circumstance, and from the neglect of the eschars for two or +three days already mentioned, I suspected the formation of a scab +under them. It was impossible to pierce the eschars by the penknife +without breaking them, as they had become too hard and thick by delay +and the addition of the scab. + +I again directed the cold poultice for four or five days. On examining +the wounds on the separation of the eschars, I found the healing +process going on. I reapplied the lunar caustic to form eschars, and I +evacuated a little fluid from their centre for three successive days. + +At this time the patient took cold and a smart attack of fever came +on, and the part round the eschars became much inflamed. I prescribed +an emetic and purge, and a cold poultice and lotion. + +In the space of a week I again attempted to form an eschar over the +larger wound, for the smaller one had quite healed. + +The next day I discharged a little fluid from the centre, and again on +the eight or nine succeeding days, giving saline purgatives. + +After this time the eschar remained adherent, and no further remedy +was required. + +This case is particularly interesting and important, as it illustrates +the plans to be adopted in two circumstances of no unfrequent +occurrence; 1. when there is an attack of fever and increased +inflammation, and 2. when a scab forms underneath the eschar. In both +cases we must relinquish our attempt to form an adherent eschar for a +time,--apply the poultice,--and recur to the caustic in the course of +a few days. + +In the beginning of my trials of the treatment of the ulcers by the +caustic, I was repeatedly betrayed by the smooth appearance of the +eschar, to think that all was going on well, when in fact a scab was +all along forming underneath. In these cases inflammation soon +followed, and it was only by carefully and daily evacuating the fluid +effused under the eschar that I at length succeeded in effecting an +adherent eschar free from surrounding inflammation. This remark cannot +be too often repeated. + + +CASE XXIX. + +The peculiarity of the present case arose from neglect in evacuating +the fluid effused under the eschar the day succeeding its formation, +the consequence of which was that the edges of the eschar became +raised all round, without however being entirely detached. + +Mr. Draper, aged 50, had a small irritable ulcer of the size of a +horse-bean, upon the shin, of a month's duration, with surrounding +inflammation to the extent of several inches. I applied the lunar +caustic to form an eschar and protected it with gold-beater's skin. + +On the following day, it appeared from the flatness of the surface, +that the eschar was adherent; the inflammation remained as before. + +On the next day the eschar was raised all round its borders, +presenting the appearance of an elevated ring. I made an opening in +one point of this ring by a penknife and evacuated the fluid, and I +again applied the caustic all round in order to give firmness to the +edges of the eschar. + +On the succeeding day an opening was made in the centre of the eschar +and a little more fluid was evacuated. + +This mode of treatment was continued daily for about a week, the +inflammation gradually subsiding and the eschar becoming adherent and +corrugated. In about three weeks, the patient thinking the sore quite +well detached the eschar; there was still, however, a minute ulcer +left, which was touched with the caustic. + + +CASE XXX. + +C. Cocking, aged 17, has an ulcer of the size of half-a-crown on the +inner part of the knee, occasioned by an accident. He had been a month +under surgical care in the country when he applied to me, but the +ulcer continued without disposition to heal, and fungous; it had +apparently been treated by a solution of sulphate of copper. I applied +the lunar caustic over the surface of the sore and upon the +surrounding skin. + +On the following day, the eschar was unadherent and puffy, and on +piercing it a little fluid escaped. The incision into the eschar was +repeated three or four successive days, but the eschar still retained +its puffy character; I therefore directed a poultice to be applied to +remove it. + +In two days the eschar was separated leaving the ulcer with its +fungous appearance. I removed the fungous part by scissors, and +directed the poultice to be applied and to be continued for two days. +I then formed another eschar. This required a daily puncture for the +evacuation of subjacent fluid, for six days; it then remained +adherent, and in about a fortnight it separated leaving the ulcerated +surface healed. This patient was not at all confined. + + +CASE XXXI. + +Mr. S. aged 30, had a sore two inches in length in the groin, the +remains of a phagedenic ulcer. It had remained stationary a whole +fortnight under the ordinary treatment by bandage. I applied the lunar +caustic to form an eschar and then the gold-beater's skin. + +The day afterwards, I found the eschar incomplete and I applied the +caustic again. The eschar was still incomplete on the following day, +and the caustic was again required to be applied to the denuded parts. + +On examination two days afterwards I found the eschar complete and +adherent. + +On the fourth following day, great part of the eschar had separated +leaving the ulcer healed, and I had no occasion to see the patient +again. + + +IV. OF SOME ANOMALOUS CASES. + + +1. _Of Whitlow._ + +The lunar caustic is very useful in the treatment of this painful +affection. Patients seldom apply to the surgeon before suppuration has +taken place. It is then, I think, the best plan to open the abscess +freely, to apply the caustic well within the cavity, and then to +envelope the part by the cold poultice and lotion. In this manner the +pain and irritation are almost immediately removed, after the smart of +the caustic has subsided. A second application is seldom necessary. +In some cases, however, there is an increase of inflammation in a day +or two, which requires the caustic to be again applied. When the +inflammation has subsided, the loose cuticle may be removed, and the +caustic must be applied to form an eschar. + +In slight cases the lunar caustic may be passed over the inflamed +part, and in this manner suppuration and the continuance of +inflammation is often prevented. + +In those cases in which the suppuration is artificial and attended +with severe diffused inflammation, the pus should be evacuated and a +cold poultice applied for a day or two; for the too early application +of the caustic would only add to this kind of inflammation; see p. 11; +afterwards the skin may be removed, and if there be excoriations the +caustic may be lightly applied. + + +2. _Of Inflammation of the Finger._ + +The following case of inflammation of the finger occurred without any +assignable cause. + + +CASE XXXI. + +A young man, aged 18, came to me with a painful swelling of the +middle finger of the right hand; suspecting deep-seated abscess, I +made a free incision and evacuated a little pus. I then applied the +lunar caustic within the cavity and directed a cold poultice to be +applied with lotion. + +On the fourth day my patient had returned to his occupation as a dyer. + + +CASE XXXII. + +Miss B. aged 23, had a slight scratch on the inside of the index +finger, which issued in severe inflammation extending over the back of +the hand. I made a free incision in the part first affected, evacuated +a little pus, and directed a poultice to be applied. + +On the following day, there was less pain but still great swelling at +the back of the hand, which, I think, would have been removed had the +caustic been used. + +I now applied the caustic freely within the orifice. + +On the following day there was less swelling and discharge. + +Two days afterwards, the caustic was again applied, and in eight days +from the first application of the caustic the hand was quite well. + + +3. _Of Fungous Ulcer of the Navel in Infants._ + +It sometimes occurs that a little fungous sore exists upon the navel +in infants which is difficult of cure in the ordinary way. I had one +case which had subsisted for two years, and another, which had +continued for two months, and were, during those periods, a source of +great trouble and uneasiness to the mothers of the little patients. +These ulcers are easily cured in the following manner. + +The fungus is to be completely removed by a pair of scissors, and when +the bleeding has quite ceased, the lunar caustic is to be applied, +and the part defended by the gold-beater's skin and kept carefully +from any moisture. + +In one of the cases mentioned above the eschar was accidentally +separated twice and required to be renewed; but both cases were cured +in the space of a few days. + + +4. _Of Inflammation of the Knee._ + +Servant women, I suspect from much kneeling in scouring stairs, &c. +are subject to a species of inflammation of the knee which is +frequently extremely troublesome. + +In one case suppuration of the integuments took place in the forepart +of the knee, and the patient was obliged to leave her situation and go +to her friends at a distance, although every antiphlogistic means was +tried for her relief. + +In two other cases, after the application of twenty leeches and the +administration of an emetic and purgative medicine, I applied the +lunar caustic freely over the whole surface of the knee previously +moistened with water. In a few hours the cuticle was raised and +vesicated; I evacuated a viscid puriform fluid, and I directed the +constant application of the cold poultice and lotion. + +In a few days all inflammation subsided and the patients remained +well. + +These three cases having occurred to me at the same time, and being +apparently equally severe, I was enabled to judge of the efficacy of +this use of the caustic, and I can strongly recommend it to a future +and further trial. Its application causes more pain than a blister, +but not so much as to form an obstacle to its employment. + +It may not be unimportant, here, to suggest the trial of the caustic +in other cases of inflammation, in which a more than usually active +local remedy is required. + + +5. _Of Tinea Capitis, &c._ + +In this place I have only to observe that I have in some cases +completely succeeded, in others completely failed, in the cure of +tinea capitis, by the lunar caustic. As I have not hitherto +distinguished these cases from each other; and as I could only offer +conjectures on the subject, I think it best to leave it for future +inquiry. + +The same observation applies to some other cutaneous affections which +I need not specify more particularly at the present. + + + + +CHAPTER III. + +OF SOME CASES IN WHICH THE CAUSTIC IS INAPPLICABLE. + + +It is by no means my intention to recommend the application of the +lunar caustic as an infallible remedy for all local diseases. I am +quite aware of the propensity, in recommending a favourite remedy, to +extend its use beyond its true limits. The caustic, like all other +remedies, requires to be employed with discrimination; and it is +therefore my object in this little work, to state in which cases it +is, and in which cases it is not, useful and successful. + +With this object, I have thought it not improper to add, in a +concluding chapter, some observations on those cases in which I have +found the lunar caustic to be inadmissible. It will, at the same time, +be found that such cases, in the course of their treatment by the +ordinary measures, not unfrequently become fit cases for the +application of the caustic, with the view of more speedily completing +the cure. + +This observation is particularly applicable to the cases of burns, of +large ulcers, of fungous ulcers, &c. + +The caustic is inapplicable in extensive lacerations, for the same +reason that it is so in extensive ulcers. + +I have found the caustic of little use in incised wounds, and should +not employ it except in such wounds received in dissection. + +I have failed in my attempts to heal scrofulous sores by the adherent +eschar; I would propose the trial with the lunar caustic and poultice. + +In erysipelatous inflammation, where vesicles are formed, the caustic +does injury, as in recent burns. + +I have always found that the caustic has done injury in boils, +aggravating rather than diminishing the affection. + + +1. _Of Burns._ + +The application of the lunar caustic in recent burns or scalds, has +always appeared to me to increase the inflammation and vesication, +even inducing blisters where there were none before. The caustic must +not, therefore, be applied in these cases, until the inflammation has +entirely subsided; but when there remains only a small superficial +ulceration, the caustic may be passed lightly over the ulcerated +surface to form an eschar which is to be defended by the gold-beater's +skin; for the affection is then reduced to the state of a common +superficial ulcer. An adherent eschar is generally readily formed, and +no further application is required. If the ulceration be more +extensive and deeper, the lunar caustic may be applied, and the eschar +treated, exactly as in common ulcers. + +It may be well to illustrate these points, by the following cases. + + +CASE XXXIII. + +A little girl, aged 10, scalded her breast a week ago and has treated +it with the ordinary remedies. There remained a superficial +ulceration of the size of half-a-crown. I applied the lunar caustic +lightly over the surface of the sore, and then the gold-beater's skin. + +On the following day, an adherent eschar had formed, and in five days +more it dropped off leaving the ulcer quite healed. + + +CASE XXXIV. + +Mr. C. aged 51, scalded his leg ten days ago on the instep. He applied +ointments and poultices. The surface remained ulcerated to the extent +of three inches in length and an inch and a half in breadth, and +presented a considerable thick slough in the centre; the inflammation +continued to be considerable with some oedema towards the toes. In +such a case I should now recommend a cold poultice to be applied for +several days; but the present case occurring early in my trials of the +caustic, the latter remedy was applied forthwith over both the ulcer +and slough. + +On the following day I learnt that the pain after the application of +the caustic had been considerable for two hours. It then ceased and +the eschar became complete; and there was rather less inflammation +and swelling. The patient had kept in bed. I prescribed a pill with +the hydrarg. submurias, to be followed by an aperient draught. + +On the succeeding day my patient went down stairs and disturbed the +eschar, and experienced more pain. The inflammation and swelling were +still less. I applied the caustic to the parts of the ulcer exposed by +the injury done to the eschar. + +During the two following days the inflammation subsided entirely; I +evacuated a little fluid from beneath the eschar. + +On the next day the eschar appeared adherent, except in the centre +which was occupied by the slough. + +On the succeeding day, I evacuated a little fluid from beneath the +slough. + +On the next day I removed the slough entirely by means of a pair of +scissors. The subjacent ulcer had a healthy granulated appearance. I +applied the lunar caustic to it to form an eschar. + +From this time it was necessary to evacuate a little fluid from under +the eschar for ten successive days. It then became adherent, and in +about a fortnight it separated, leaving the ulcer healed. + + +CASE XXXV. + +The following case will present a specimen of my trials of the lunar +caustic in larger ulcers. + +Anthony Knowles, aged 44, was kicked by a horse on the leg, above the +inner ankle, two years ago. The part has never healed, but still +remains in the state of an open ulcer, attended by some inflammation. +When I first saw this ulcer it was about two inches in diameter and +nearly circular, with high edges, a surface of a greenish colour, and +without any healthy granulations. I applied the lunar caustic to form +an eschar. + +The pain from the caustic was severe for several hours. An eschar had +formed round the edges, but in the middle part it was quite wanting; +the inflammation surrounding the ulcer had abated, and the green hue +of its surface had disappeared. I reapplied the caustic in the central +part. + +On the following day the eschar appeared tolerably complete in the +centre but had separated at one part of the circumference. I again +applied the caustic to the defective part. + +On the following day the eschar was defective in several parts, but +the inflammation was quite removed, there was no pain, and there had +been less smarting after each successive application of the caustic. I +again applied the caustic. + +On the succeeding day, I learnt that my patient had been intoxicated, +and I found the ulcer attended by inflammation. The eschar was by no +means complete; some part of it was in a detached state. I removed +the loose portions and repeated the application of the caustic. + +This sort of treatment was continued for a fortnight without my being +able to effect the formation of a complete eschar. I therefore +relinquished the idea of healing the ulcer by the adherent eschar; I +eventually succeeded in doing so by applying the caustic every third +day and the poultice continually, and I had hopes that the cure might +be permanent, but he made application to me in two years afterwards +with a similar ulcer on the same part. + +In another similar case, I removed the elevated hard edges of the +ulcer by the lancet, and then tried the caustic, without better +success. + + +CASE XXXVI. + +The last case I have to give is one of great interest, as it clearly +shows the influence of the lunar caustic in subduing the inflammation +surrounding ulcerations, and in promoting the healing process, even in +cases of phagedenic ulcer. In such cases its influence eminently +deserves a still further trial. + +Mrs. H. aged 56, has had very extensive phagedenic ulcerations on the +legs and thighs during three years, which began in little red spots +and then spread rapidly, destroying the integuments. One of these +ulcers, on the thigh, was twelve inches in length and five in breadth, +and exhibited the appearance of a deep corroding furrow; it was +surrounded by a fiery redness and was attended by extreme pain. There +were many other ulcers of the same kind, several nearly of the same +magnitude; and the poor patient was compelled to take large doses of +laudanum several times in the day. She had formerly been treated for +syphilis, and had afterwards taken the sarsaparilla freely; amongst a +great variety of local applications, the white bread poultice had +afforded most relief. + +I applied the lunar caustic to two of the smaller ulcers. + +On the following day the eschars were complete. I applied the caustic +to the large sore above described to the extent of three inches +square, avoiding its application on the inflamed skin. + +On the next day I found the eschar last made complete, and I passed +the caustic over the ulcer to the extent of three inches more. + +On the succeeding day, the eschar was complete, adherent at those +edges which adjoined the cuticle, and floating at the other edges over +the ulcer, and in the latter part allowing the escape of matter; round +the adherent edges of the eschar the inflammation had entirely +disappeared, while it remained fiery as before round every other part +of the ulcer. + +I continued my trials with the caustic in this case, but it gave so +much pain, and I had so little hope of final success, that I +altogether relinquished the attempt to treat these ulcers by eschar. +Some of the small ulcers were healed, however, and the larger one +assumed a more healthy character wherever the caustic had been +applied. It may, therefore, remain a question whether the lunar +caustic may not still prove useful in phagedenic ulcers of a smaller +size. + + + +FINIS. + + + + +T. Wheelhouse, Printer, +Nottingham. + + * * * * * + + +--------------------------------------------------------+ + | Typographical errors corrected in text: | + | | + | Page 41: cautic replaced with caustic | + | Page 65: eurative replaced with curative | + | Page 107: smuch replaced with much | + | Page 120: ANOMOLOUS replaced with ANOMALOUS | + | | + +--------------------------------------------------------+ + + + + + +End of the Project Gutenberg EBook of An Essay on the Application of the +Lunar Caustic in the Cure of Certain Wounds and Ulcers, by John Higginbottom + +*** END OF THIS PROJECT GUTENBERG EBOOK LUNAR CAUSTIC *** + +***** This file should be named 23729.txt or 23729.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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