An Essay on the Application of the Lunar Caustic in the Cure of Certain Wounds and Ulcers Part 5

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 s.h.i.+lling, 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 circ.u.mstance, 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 s.p.a.ce 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 ill.u.s.trates the plans to be adopted in two circ.u.mstances 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 s.h.i.+n, 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 x.x.x.

C. c.o.c.king, 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 x.x.xI.

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.