An Essay on the Application of the Lunar Caustic in the Cure of Certain Wounds and Ulcers Part 4

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 circ.u.mstances 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 circ.u.mstances 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 s.h.i.+lling, 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 hoa.r.s.eness 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 s.h.i.+n, 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 s.h.i.+n 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 ill.u.s.trates 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 s.h.i.+lling 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 sh.o.r.e 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.