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ON THE

LUNAR CAUSTIC. 

ANESSAYON THEAPPLICATIONOFTHE LUNAR CAUSTIC, IN THE_CURE OF CERTAIN_WOUNDS AND ULCERS. 

BYJOHN HIGGINBOTTOM, _NOTTINGHAM_, MEMBER OF THE ROYAL COLLEGE OF SURGEONSOF LONDON. 

LONDON:PRINTED FORLONGMAN, REES, ORME, BROWN, AND GREEN, _PATER-NOSTER ROW_. 1826. 

T. WHEELHOUSE, PRINTER, NOTTINGHAM. 

TOMY BROTHER-IN-LAW, MARSHALL HALL, M. D. F. R. S. E. 

&c. &c. THIS LITTLE WORK IS INSCRIBEDWITHGREAT AFFECTION. 

_Nottingham, Jan. 6, 1826. _

PREFACE. 

The following pages are presented to the medical public with veryhumble pretensions. It is chiefly with the minor accidents or diseasesthat they have to do; but I shall not consider that I have laboured invain, if I am enabled to mitigate even these little evils of humanlife. 

In these prefatory observations, however, I would suggest the questionwhether the caustic may not be employed with benefit even in some ofthe severer diseases to which the human frame is liable. Indeed Iconsider the investigation as only just begun, and many other uses ofthe lunar caustic, besides those detailed in the following pages, havesuggested themselves to me. 

May not the caustic, for instance, be of greater efficacy, because ofgreater power and of quicker operation, than ordinary blisters, insome internal diseases?

It is repeatedly stated hereafter, that the application of the lunarcaustic is a means, in certain circumstances, of subduing externalinflammation. Might it not, on this principle, be of service in thetreatment of some of the internal phlegmasiĉ?

It may be observed, that the lunar caustic may be regarded, almostwithout further trial, as an effectual preventive of those cases ofirritative fever which arise from local injuries, and probably of theeffects of poisoned wounds in general. I would not, however, in thelatter cases, fail to render "sure doubly sure" by free excision. 

Might not an adherent eschar be easily formed in those cases ofcompound fracture in which the external wound is of moderate size, soas effectually to exclude the external air and prevent cutaneousinflammation, and in more respects than one, to reduce the case to thestate of a simple fracture? This object, if attained, would beimportant indeed, and I hope the suggestion will be submitted to themost assiduous and cautious trial. 

I can have no doubt that the use of the lunar caustic admits of beingstill further extended; and, as I intend to pursue the inquiry, I hopeat some future period to publish something more worthy of theattention of the medical public. In the mean time, the plans hereaftersuggested must not be adopted without that degree of care, attention, and perseverance, which are obviously necessary to render themsuccessful. 

CONTENTS. 

CHAPTER I. PAGEON HEALING BY ESCHAR 1

 I. _Of the Adherent Eschar_ 3 II. _Of the Unadherent Eschar_ 14III. _On the Treatment by Eschar and Poultice_ 21

CHAPTER II. 

OF THE APPLICATION OF THESE MODES OF TREATMENT TODIFFERENT CASES 24

 I. _Of Punctures, Bites, &c_ 24 II. _Of Bruised Wounds_ 64III. _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 theLunar Caustic in the treatment of Wounds and Ulcers, and having greatreason, from these trials, to think that this remedy may be used withmuch advantage far more extensively than has hitherto been done, I laythe results of my experience before my medical brethren. 

A very natural mode of healing certain wounds and ulcers, is byscabbing; but this mode of treatment is attended by manydisadvantages, as will be pointed out shortly; yet it may be supposedto have suggested to me some of those trials of the treatment byeschar, which I am about to detail. 

I. ON THE ADHERENT ESCHAR. 

It appears scarcely necessary to describe the immediate and well knowneffects of the application of the lunar caustic to the surface of awound or ulcer. It may, however, be shortly observed that the contactof the caustic induces, at first, a white film or eschar which, whenexposed to the air, assumes in a few hours a darker colour, and at alater period, becomes black; as the eschar undergoes these changes ofcolour it gradually becomes harder and resembles a bit of stickingplaster; in the course of a few days, according to the size and stateof the wound, the eschar becomes corrugated and begins to separate atits edges, and at length peels off altogether, leaving the surface ofthe sore underneath, in a healed state. 

In the formation of this eschar several things require particularattention. The application of the caustic should be made over thewhole surface of the sore; and indeed no part requires so muchattention as the edges; to make a firmer eschar the caustic shouldeven be applied beyond the edge of the wound, upon the surroundingskin, for the eschar in drying is apt to contract a little, and inthis manner may leave a space between its edges and that of theadjacent healthy skin. 

At the same time, much attention must be paid to the degree in whichthe caustic is applied. In cases of recent wounds unattended byinflammation, it may be applied freely; but when inflammation has comeon, too severe an application of the caustic induces vesication of thesurrounding skin, and the edges of the eschar may in this manner alsobe loosened and removed. If every part is touched, a slightapplication of the caustic is generally sufficient. 

The importance of avoiding all causes which might detach the edges ofthe eschar will be apprehended by the following interestingobservation, which I have been enabled to deduce from very extensivetrials of the caustic; it is, that, in every instance in which theeschar remains adherent from the first application, the wound or ulcerover which it is formed, invariably heals. 

Not only the cause just mentioned, but every other by which the escharmight be disturbed, must, therefore, be carefully avoided; andespecially, as the eschar begins to separate from the healed edges ofthe sore, it should be carefully removed by a pair of scissors. 

To the surface of the wound the eschar supplies a complete protectionand defence, and allows the healing process to go on underneathuninterruptedly and undisturbed. It renders all applications, such asplasters, totally unnecessary, as well as the repeated dressings towhich recourse is usually had in such cases; and it at once removesthe soreness necessarily attendant on an ulcerated surface beingexposed to the open air. In many cases too, in which the patients areusually rendered incapable of following their wonted avocations, thismode 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 shouldbe preserved adherent. To secure this still more effectually, I havefound it of great utility to protect it by a portion of gold-beater'sskin. The skin surrounding the wound is simply moistened with a dropof water, and the gold-beater's skin is then to be applied over it andover the eschar, to which it soon adheres firmly, but from which itmay be removed at any time, by again moistening it for a moment withwater; the same bit of gold-beater's skin admits of being again andagain reapplied in the same manner. 

The other circumstances which render the eschar unadherent will bementioned hereafter. In the mean time the fact stated p. 6, willsufficiently establish the propriety of treating distinctly of theadherent eschar. 

I now proceed to mention some other effects of the application of thecaustic. The first is that, in cases in which there would be much andlong continued irritability and pain, as in superficial wounds alongthe shin, all this suffering, and its consequences in disabling thepatient, are completely avoided. A blush of inflammation forms aroundthe eschar, but this gradually subsides without any disagreeableconsequences, and the inflammation which would otherwise have been setup 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 notsevere, and if the eschar remain adherent, all inflammation, both thatinduced by the application of the caustic, and that existingpreviously, entirely subsides. When the previous inflammation roundthe ulcer is considerable, however, the application of the causticwould induce vesication, and it should in such a case of course beavoided, and another mode of treatment to be described hereafter mustbe adopted. 

I would introduce in this place some observations on the comparativeeffects of healing by eschar and by scabbing. On the subject ofscabbing I must refer my reader to the well known work of Mr. JohnHunter. The advantage of healing by eschar over that by scabbing isquite decided. By comparative trials, I have found that whilst thescab is irritable and painful, and surrounded by a ring ofinflammation, the adherent eschar is totally free from pain andinflammation; and that whilst the scab remains attended byinflammation and unhealed, the eschar is gradually separating, leavingthe surface underneath completely healed. To these observations I mayadd that the success of the plan of healing by eschar is infinitelymore certain as well as more speedy than that by scabbing. 

I shall, in conclusion, briefly recapitulate the advantages of thismode of treatment. In the first place, it will be found far moreefficacious and speedy than any other; secondly, it has the greatadvantage of saving the patient much suffering and inconvenience; andthirdly, it renders the repeated application of dressings andointments quite unnecessary. Its utility is extremely great, therefore, where the time of the poor, the expense of anestablishment, and the labours of the medical officer, as well as thesufferings of the patient, require to be considered; and it will Iimagine be found of no little advantage, in all these respects, inmany 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 insmall ulcers, when they are nearly even with the skin and attended bylittle inflammation. In other cases the eschar is too apt to beunadherent, and this arises from the formation of pus or of a scabunderneath. 

If the eschar be unadherent by subjacent pus, it may be ascertained inthe space of from twelve to twenty-four hours; the centre is generallyobserved to be raised and to yield to the pressure of a probe;sometimes the subjacent fluid has partly escaped by an opening at theside of the eschar. 

When a scab forms underneath the eschar, which does not happen exceptthe fluid has been allowed to remain too long under the eschar withoutbeing evacuated, there are pain and some inflammation, the eschar doesnot separate, but remains long over the sore, and there is noappearance of healing. 

When it is ascertained that there is fluid underneath the eschar, aslight puncture is to be made by the point of a penknife, the fluid isto be gently pressed out, and the caustic is then to be applied tothe orifice thus made. The same plan is to be adopted if the fluidooze out at the edge of the eschar; it is to be fully evacuated bypressure, and the orifice is to be touched with the caustic. Thehealing process goes on best however when the orifice is in the centreof the eschar. After this treatment the eschar occasionally remainsadherent, but more frequently the fluid requires to be evacuatedrepeatedly, and this should be done every twelve hours, or once a day, according to the quantity of fluid formed, taking care that the escharbe not needlessly separated by allowing the fluid to accumulateunderneath. If, from accident, the eschar is separated before the sorebe healed I would reapply the caustic. At length the eschar becomesadherent, and in due time begins to peel off, leaving the surfacehealed. 

In every case in which the eschar does not separate favourably, Ibegin to suspect the formation of a scab underneath, in which case thewhole must be removed by the application of a cold poultice for two orthree days; this has not only the effect of removing the eschar but ofallaying any inflammation or irritation; afterwards the caustic mustbe reapplied as before. 

The gold-beater's skin is more useful as a protection to theunadherent than to the adherent eschar, as the former would be moreliable to be torn off by accident than the latter. The gold-beater'sskin must be removed in the manner already described, whenever thesubjacent fluid is to be evacuated, and must be reapplied aftertouching the orifice with caustic. 

The pain experienced on the application of the caustic is greater orless according to the sensibility and size of the wound. In smallwounds it is trifling, and of short duration; it is more severe inrecent wounds than in ulcers; it soon subsides in every case, andthen the patient enjoys greater ease than would be experienced underany other mode of treatment. Little or no pain is caused on applyingthe caustic after evacuating the subjacent fluid of an unadherenteschar. Altogether the pain inflicted by the caustic is far less thanis generally imagined, and forms scarcely an obstacle to itsemployment. 

It may be proper, in this place, to notice such circumstances asrender the employment of the caustic improper or inefficient. It isimproper to employ the caustic when the ulcer is too large to admit ofthe formation of a complete eschar; or when it is so situated as torender it impossible that the eschar should remain undisturbed, asbetween the toes, unless, indeed, the patient be confined to hisbed;--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, thatthe newly prepared lunar caustic is more apt to dissolve on beingapplied than that which has been longer made and more exposed to theair; 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 oftreatment by the adherent or the unadherent eschar, it is of greatutility to apply the caustic first and then a cold poultice madewithout lard or oil: this plan is particularly useful in cases ofpunctured wounds attended by much pain and swelling, and in cases ofrecently opened abscesses. By this application the pain and swellingare 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 causticevery second or third day, or every day if the inflammation andswelling of the part be considerable, and the cold poultice may berenewed about every eight hours. At length, however, the inflammationhaving subsided, the attempt may be made to form an adherent eschar. 

I have seen many cases, in which, by this mode of treatment, muchsuffering and perhaps the loss of some of the smaller joints have beenprevented, particularly cases of deep seated inflammation of thefingers, which, having been neglected, have issued in severeinflammation, abscess, and terrible fungous growths. In these cases itis 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 skinshould be moistened with a drop of water; the caustic should then beapplied within the puncture until a little pain be felt, and then overthe surrounding skin, and the eschar must be allowed to dry. In thismanner it is astonishing how completely the terrible effects of apunctured 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 beenneglected, some degree of inflammation is usually present, the orificeis nearly closed with the swelling, and a little pus or fluid isformed within. A slight pressure will evacuate this fluid, the causticmay then be applied within the puncture, and over the surroundingskin, beyond the inflammation, and must be allowed to dry. In thismanner we frequently succeed in forming an adherent eschar, and allinflammation subsides. Any slight vesication which may be raisedaround punctured wounds is not of the same consequence as when anadherent eschar is wished to be formed over a sore or ulcer; one ormore small punctures may be made to evacuate the fluid and the partmay be allowed to dry. 

If there is reason to think that an abscess has actually formed underthe puncture to any extent, it must be opened freely by a lancet andtreated with caustic and poultice, keeping the poultice moist and coldwith water. 

In cases of puncture where the orifice is healed and where anerysipelatous inflammation is spreading, attended with swelling, Ihave applied the caustic freely over and beyond the inflamed parts, and I have had the satisfaction to find that the inflammation has beenarrested in its progress and has shortly subsided. 

This mode of treatment is particularly useful in cases of puncturedand 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 objectionwould 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 bythis treatment. I have for the last five years had frequentopportunities of trying it in these cases and have the most perfectconfidence in its success. 

The advantage of these modes of treating punctured wounds will howeverbe best explained and established by a selection of cases, to which Ican add particular remarks as they may be suggested by peculiaritiesin the cases themselves. 

CASE I. 

A. B. Received a severe punctured wound by a hook of the size of acrow-quill, which pierced into the flesh between the thumb andfore-finger on the outside of the hand; scarcely a drop of bloodfollowed, but there was immediately severe pain and tumefaction. Thelunar caustic was applied without loss of time, deep within theorifice and around the edge of the wound; and the eschar was left todry. The smarting pain induced by the caustic was severe for a timebut 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 ofthe caustic, owing to the mobility of the part. 

On the third day the swelling remained as before, and there was alittle sense of heat. On the fourth day the swelling and heat hadsubsided, and the eschar remained adherent. On the succeeding day theeschar had been removed by washing the hand, and the puncture wasunhealed but free from pain and irritation. The caustic wasreapplied. 

From this time the eschar remained adherent, and at length graduallyseparated leaving the part perfectly well. 

It is quite certain that under any other mode of treatment this severepuncture would have greatly inflamed and have proved very painful andtroublesome; and it is not improbable but that suppuration and muchsuffering might have ensued. All this is effectually and almostcertainly prevented if the caustic be applied promptly, as in thiscase. When time has been lost, the case is very different as willappear hereafter; but even in these cases, the caustic proves aninvaluable application. 

CASE II. 

Mrs. Middleton, aged 40, wounded her wrist, on the ulnar side, by thehook of a door post; there was a considerable flow of blood at first, but this ceased suddenly and the arm immediately became affected withgreat pain and swelling. The lunar caustic was applied in half an hourafter the accident. 

On the following day the eschar was observed to be adherent, and thepatient reported that she had suffered scarcely any pain, after thesmarting of the caustic had ceased. There was a slight swelling roundthe puncture but that of the arm had totally subsided. The caustic wasapplied over and beyond the swelling. On the third day all tumefactionhad subsided and there was no complaint whatever. 

I hoped that this case would have required no further attention orremedy. But my patient contrived unfortunately to rub off the escharabout a week after its formation, and so to expose the subjacent woundunhealed; she suffered however no pain or inconvenience from it; andit was again shielded by means of a fresh eschar, which remainedadherent until removed by the healing process underneath. 

This puncture was so severe that the arm was in a state of ecchymosisfor six or eight inches upwards, and I doubt not that without thecaustic, 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; theresucceeded much pain and swelling, and it appeared that the nail wouldseparate, and the cuticle all round the finger was raised by theeffusion of fluid. This fluid was evacuated and a poultice applied. 

On the third day the cuticle was removed, and the exposed surface wasfound to be ulcerated in several spots. The lunar caustic was passedslightly over the excoriated surface, which was then left exposed todry. 

On the succeeding day the eschar was adherent and the pain had almostsubsided. On the next day, the eschar still remained adherent, and asthere was neither pain nor soreness, the patient used her finger. 

The eschar was at length removed by the healing process and wasseparated together with the nail, and the case was unattended by anyfurther inconvenience or trouble either to the patient or myself. 

It is scarcely necessary to contrast the advantage of this mode oftreatment with that by plasters, poultices, &c. It is at once morespeedy and secure, and less cumbersome to such patients as are obligedto continue domestic avocations. 

CASE IV. 

The present case is somewhat more severe than those which have beenalready given, and what is of great importance, the caustic was notapplied immediately after the accident. 

William Chantry, aged 50, received a stab in the wrist with a hay-forkyesterday and applied a poultice; to-day there are great pain andswelling, and the wounded orifice is very small. I applied the lunarcaustic within the puncture, and directly a cold poultice to be wornover it; the arm was kept in a sling. 

The next day the swelling and pain were diminished, and a little lymphflowed from the wound. I again applied the caustic and continued thepoultice. 

Two days afterwards, the swelling and pain were nearly gone. Thepoultice was merely continued, the caustic not being requisite fromthe subsidence of the inflammation. The patient came to me again infour days more quite free from pain and swelling. The poultice wasdiscontinued, and the caustic was then applied in order to form anadherent eschar, in which I was successful. 

This case illustrates many important points; 1. It shows the efficacyof the caustic with the poultice as a remedy against inflammation; 2. It presents an instance of a labouring man returning to work on thesixth or seventh day after a severe accident, even when theapplication of the caustic had been unfortunately delayed; 3. Itpoints out the proper treatment, when all hope of the treatment fromthe first by adherent eschar is lost from such delay, --for had thisbeen attempted in this case, suppuration would doubtless have takenplace from the closed state of the puncture by the swelling;--ourobjects must therefore be, to open the puncture and to subdue theinflammation, and these objects are admirably attained by means of thecaustic. 

The following case is not less instructive. 

CASE V. 

Mr. Cocking's son, aged 12, received a stab in the palm of the handfrom a penknife three days ago, which has been followed by muchswelling and pain, the punctured orifice being nearly closed. Iapplied the lunar caustic as deep as possible within the puncture anddirected a cold poultice to be laid over the whole hand. 

On the next day I found that the poultice had not been applied; therewere more pain and swelling; an eschar was formed over the puncturewhich I removed and thus gave issue to a considerable quantity ofpus; I again enjoined the application of a cold poultice keptconstantly moist and cold with water. 

On the succeeding day, the inflammation had greatly subsided. Irepeated the application of the caustic and poultice. On the fourthday the inflammation had nearly disappeared and on the fifth entirely. 

In such cases the caustic unites the advantages of at once opening thepuncture and of subduing the inflammation, thus preventing theformation 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. Iapplied the lunar caustic deeply in the wound, and directed a poulticeand a cold lotion to be kept upon the inflamed parts; and suspectingfascial inflammation, I took away ten ounces of blood and administeredpurgative medicine. 

On the next day, the inflammation had greatly subsided; the cataplasmand lotion were continued. 

On the third day, there was some inflammation round the puncture whichappeared to be closing; I repeated the application of the causticwithin 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 nooccasion for any remedy, and the little patient speedily recovered. 

CASE VII. 

Mr. Parr, aged 30, of delicate habit, trod upon a needle which piercedthe ball of the great toe; a free crucial incision was made but theneedle could not be found; a poultice was applied to the wound andover the poultice a cold lotion. 

In the course of a week part of the needle came away. He did not restas he was enjoined to do, and, in consequence, severe inflammationcame on, and in two days time, fluctuation was perceived over thejoint, opposite to the puncture; a free incision was made, and somepus was evacuated. 

On the following day there was a free discharge, but very considerableinflammation had taken place on the side of the ball of the toe; afree incision was made in this part, and a fresh quantity of pus wasevacuated. 

On the succeeding day, the inflammation was somewhat abated; but onthe next day, it had again become exasperated, and the openings madefor the evacuation of matter were somewhat closed by the swelling. Inow introduced the lunar caustic very freely into these openings, andreapplied a cold poultice and lotion. 

On the following day, I found that my patient had slept well for thefirst time since the developement of inflammation, and had sufferedfar less, after the smarting pain from the application of the caustichad subsided, than before; the punctured orifices were open, and theskin, which was extremely tense the day before, was become soft andflexible. 

From this time, I found nothing necessary but to repeat theapplication of the caustic about every third day to subdueinflammation and to keep the wounds open, which it always effected. The joint ever afterwards remained stiff, from which we may infer theviolence of the inflammation; and when we consider what was theconstitution of my patient, we cannot, I think, doubt that the causticprevented many serious events usually consequent in such cases underthe ordinary treatment. 

It is highly worthy of remark, that the good effects of theapplication of the caustic, in this case, were too immediate anddistinct to be mistaken. 

CASE VIII. 

This case illustrates the mode of treatment by the lunar caustic, ofthose terrible effects of punctured wounds which have been neglectedin the beginning. 

B. Unwin, aged 40, washerwoman, applied to me on July the 10th, 1820, with severe inflammation and ulceration of the middle finger, arisingfrom a puncture by a pin or needle some time before; there was muchpainful tumefaction, and the integuments had burst along nearly halfof the length of the finger, on the ulnar side, and over the middlejoint on the radial side; the probe did not however pass to the boneor into the joint. I applied the lunar caustic deep in every part, andover the whole surface, and enveloped the finger in a cold poulticecovered with cold water. 

On the 11th she reported that she had slept well for the first timeduring the last fortnight; to-day there is scarcely any pain, but shecomplains of soreness; the swelling has greatly subsided. The causticwas again applied and the poultice and lotion continued. 

On the 12th there were still swelling and pain; there was considerablebleeding from the wound, so that I could not apply the caustic well. 

On the 13th the swelling and pain were nearly gone. I repeated thecaustic which induced bleeding from the fungous flesh. 

On the 14th the swelling had nearly subsided; the cuticle wasseparating all over the finger. The lunar caustic was appliedextensively over the wound and abraded parts and induced littlebleeding or pain. 

On the 15th the fungous was nearly removed; the wound presented anappearance of slough over its surface. --The caustic was applied to theremaining fungous. 

On the 17th the wound was much smaller and the slough separating. Thecaustic and cataplasm were applied as before. --A similar report wasmade on the succeeding day. 

On the 20th the slough was separating. The caustic and cataplasm wereapplied. --A similar report was made on the 22d. 

On the 24th the slough having separated the integuments over it wereflabby and loose; the caustic was applied to them. 

By a continuation of this plan the wound gradually contracted, and, atlength, when there was no further use for the cataplasm, the escharbecame adherent and the sore healed underneath. It appeared highlyprobable to me that, under ordinary treatment, the finger, in thiscase, would have been lost. 

 * * * * *

I shall in this place, introduce a few observations on wounds receivedduring dissection. 

It is not in my power to give any cases in illustration of thetreatment of the severer accidents resulting from these wounds; forsince I began the free use of the lunar caustic all the terribleeffects of such wounds have been invariably prevented. 

I may here mention that in the years 1813 and 1819, respectively, Iwas myself exposed to great danger from inoculation during theexamination of dead bodies. Since the latter period I have repeatedlybeen exposed to the same danger from inoculation, but in everyinstance, the danger has been completely averted by the prompt andfree application of the lunar caustic. 

The following is the exact mode of treatment which I would adopt insuch cases. 

In recent punctures the caustic should be applied in the manneralready described in cases of simple punctured wounds. 

When the case has been neglected, a small tumour is usually formedunderneath the skin with smart stinging pain; this tumour should beremoved entirely by the lancet, and the caustic should be applied, both to the surface of the wound and over the surrounding skin, toform an adherent eschar. 

When the case has been still longer neglected, and inflammation of theabsorbents has supervened, a free crucial incision is to be made, thecaustic is to be very freely applied, and afterwards a cold poulticeand lotion, the usual constitutional remedies being actively enforced. 

 * * * * *

In connexion with punctured wounds I here subjoin several cases of thebites of animals. 

CASE IX. 

James Joynes, aged 12, was bitten by an ass, on each side of themiddle finger; the wounds were severe, and almost immediatelyfollowed by swelling and great pain. The lunar caustic was wellapplied within half an hour after the accident. 

On the succeeding day, the eschar was found to be quite adherent, andthe 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 bittenseverely on the face and forehead in three places; one of the woundsin 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 inhalf an hour after the accident to each of the wounds, and the escharwas covered with gold-beater's skin. 

On the next day the eschars were adherent. There was some swellingfrom the severity of the bruise; but the child made little complaint. 

On the third day, the swelling remained as before and the escharadherent. On the fourth, the swelling had nearly disappeared. --Theeschar 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 fortnightago. There is now a very irritable, inflamed, fungous sore. I removedthe fungous by a pair of scissors and applied the lunar caustic toform an eschar. 

On the succeeding day, I found that the patient had applied a littlelint before the eschar was dry, which had prevented it from remainingadherent. I reapplied the caustic and desired that the eschar might beexposed to dry. 

The eschar remained adherent, the inflammation subsided and the casegave no further trouble. 

CASE XII. 

A servant maid was bitten by a dog in four places--severely on theforearm--three days ago. Adhesive plaster had been applied. There is awound across the arm two inches in length and three-fourths of an inchin breadth, attended by dull pain, and swelling of the arm. I appliedthe caustic to form an eschar, covering it with goldbeater's skin. 

On the following day the eschar remained adherent round the edges, buthad a puffy feel in the centre; I pierced it with a penknife and alittle bloody fluid escaped, and I touched the orifice thus made withthe caustic. The swelling remained as before, with a degree ofsoreness. 

On the next day the swelling had subsided. The eschar had the samecharacter; a little fluid was again evacuated and the caustic appliedto the orifice as before. 

This mode of treatment was pursued for nine successive days when theeschar remained adherent in every part. 

This patient continued her usual avocations all along. Under any otherplan of treatment I think it impossible that she should not have beencompelled to rest for a number of days. 

Adherent eschars were formed on the other three bites which were lesssevere, from the first application. 

A very irritable sore sometimes forms after the application ofleeches. I knew one lady who was confined during five weeks withseveral sores on her foot from such a case. I have no doubt that theapplication of the caustic would have prevented all the inconvenienceand suffering she experienced. This observation will be confirmed bythe following case. 

CASE XIII. 

Am old man applied leeches to the instep for inflammation occasionedby a bruise. Several very irritable sores were produced with someswelling. I applied the lunar caustic to form an eschar. 

On the following day, the eschars were adherent, the swelling hadsubsided, and he had slept well for the first time of several nights. 

I do not, however, think the lunar caustic would succeed in such casesif attended by great inflammation, without the previous application ofa cold poultice with rest for a day or two. 

II. ON BRUISES. 

It has been already observed, p. 9, that the caustic is an invaluableremedy in cases of bruised wounds of the shin. In these, as in allother cases, the value of this remedy is greatly enhanced by an earlyapplication. In bruises on the shin I have not had a single instancein which I was not enabled to effect a cure by the adherent eschar, ifapplication was made to me early. The difficulty of forming anadherent eschar is always increased by delay; but in these bruisesalong the shin there is an additional reason for this increaseddifficulty, arising out of the tendency observed in them, to theformation of a slough. 

In this place I have, indeed, to make an observation of particularinterest, both in a pathological and curative point of view; it is, that the formation of this slough has always been prevented by anearly application of the caustic, in the cases which have hithertofallen under my care. This fact may probably admit of explanation inthe following manner; the bruise partially destroys the organizationof the part, and the subsequent inflammation completing what theinjury had partially effected, a loss of vitality takes place, andthe slough is formed. The early application of the caustic hasalready been shown to have the remarkable effect of preventing theinflammation consequent upon certain wounds, and thus the part issuffered to recover from the injury done to its organization, and itsvitality is preserved. 

Whether this mode of explaining the fact be correct or no, the factitself is extremely important, for the formation of a slough, whichthe early application of the caustic can alone prevent, renders itquite impossible to effect the formation of an adherent eschar. 

When the patient applies too late after the accident to prevent theformation of a slough we must still treat the case by the caustic. Itis to be applied over the bruised and inflamed part. The escharremains adherent round the part occupied by the slough and prevents ormoderates the inflammation, and when the slough separates an eschar isto be formed over the exposed sore. 

In the neglected and severer cases of bruise attended by muchinflammation, it will be found best to treat the part for a day or twoby a cold poultice to give time for the inflammation to subside;otherwise the caustic might induce vesication of the skin, as I havementioned 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 willserve to illustrate the mode of treatment by the adherent eschar. 

Mr. Symons, aged 60, slipped off a chair and bruised the shin, lastevening; the skin was removed to the extent of an inch in one part anda square inch in another. He applied a common poultice. During thenight he had much pain, and to-day there is much inflammation roundthe wounds. I applied the lunar caustic over both wounds and coveredthe eschar with gold-beater's skin to prevent the contact of thestocking. 

On the following day the eschar was found to be perfect. The pain hadentirely ceased. There was a little vesication round one of thewounds. I simply evacuated the fluid of the vesication and left thepart exposed to dry. 

On the third day there was no pain or inflammation, and the escharremained adherent. 

From this time no remedy was required. The eschar separated leavingthe surface healed, in about a month from the occurrence of theaccident. The patient suffered no sort of inconvenience nor was heconfined from his labours a single day. 

CASE XV. 

The following case was far more severe, but the mode of treatment wasnot less efficacious. 

Mr. Granger, aged 36, was exposed to a severe bruise by a great weightof stones which had been piled up, falling upon the outside of theleg; he was extricated from this situation with much difficulty. Besides the bruise, the skin was removed from the outside of the legto the extent of ten or twelve inches in length, and in some parts aninch and half in breadth; and in the forepart of the ankle a deepfurrow was made by the rough edge of one of the stones. I applied thecaustic in about half an hour after the accident, over the wholesurface of the wounds, and protected the eschar by the gold-beater'sskin. The patient was directed to keep the leg cool and exposed to theair. He took no medicine. 

On the succeeding day the leg was a little swelled, but the patientdid 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 wholeextent of the wound. There was no fever. 

On the third day, the swelling had abated. No further remedy. Thepatient was still enjoined to rest. 

On the fourth day the swelling was nearly gone. The eschar remainedadherent. The patient walks about. 

From this time the patient pursued his avocation of a stone-mason; nofurther remedy was required; no inconvenience experienced; and theeschar separated in about a month. 

I think it totally impossible to have cured this wound, by any otherremedy, in less than a month; during which period the patient musthave suffered much pain and fever, and have been quite confined. 

It is also quite certain, I think, that there would have been anextensive slough, from the severity of the bruise. This was doubtlessprevented by the application of the caustic. 

CASE XVI. 

J. Jennings, bricklayer, aged 26, fell through the roof of a house andbruised and lacerated his shin rather severely to the extent of aninch and half in one part and in several other places in a lessdegree. I applied the lunar caustic to the wound immediately. 

On the following day the eschar was found to be adherent, and therewas 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 overthe wound according to the severity and exigency of the case. Thiscase being less severe than the former one the eschar remained uponthe 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. Iapplied the lunar caustic soon after the accident. 

On the next day an adherent eschar was formed. There was neither painnor swelling. --The eschar separated in a fortnight. 

CASE XVIII. 

Mrs. C. Aged 40, was detained on a journey by a bruised wound on herknee, received a fortnight before, which was healing very slowly underthe usual mode of treatment. The inflammation was subsiding but thesore was extremely irritable and painful, and she was prevented frommoving. From the degree of inflammation still present, I applied thelunar caustic very slightly over the sore and not over the inflamedskin; I left the eschar to dry, but was very doubtful, from the samecause, whether it would be adherent or no. 

On the succeeding day I found that the eschar did remain adherent andthat the inflammation was diminished, and the soreness had entirelysubsided after that induced by the caustic had ceased. 

On the next day, the lameness was gone, and there was no sort ofinconvenience from the wound. My patient continued her journey on thefollowing day, so that I do not know when the eschar separated. 

In regard to the inflammation attendant on these wounds, I wouldremark that slight inflammation is relieved by the application of thelunar caustic and does not prevent the formation of an adherenteschar; but very severe inflammation requires the application of thecold poultice and lotion over the wound, and it is necessary to watchfor 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 inflammationattendant on a recent wound is removed by the caustic, when the samedegree of inflammation at a later period, and with suppuration, wouldbe aggravated and require the cold poultice and lotion, and renderthe formation of an adherent eschar impossible. This fact, the resultof much experience, is extremely interesting, and, I think, not easyto be explained. It is illustrated by the following case. 

CASE XIX. 

Robert Hill, aged 16, received a blow yesterday from a bone which wasthrown at him, upon the outer condyle of the humerus. He complains ofextreme pain and there are much redness and swelling. I applied thelunar caustic and directed the part to be exposed to the cold air. 

On the succeeding day, I found that the eschar was quite adherent, andthat the pain, redness and swelling had much subsided, although therewas some stiffness of the elbow. 

On the third day there was still further amendment. From this time noremedy or attention was required. 

CASE XX. 

It frequently occurs to surgeons to receive slight wounds upon thehands which prove very troublesome. Of this kind is the following. 

Mr. L. C. Had an irritable and inflamed sore on the ulnar side of thethird finger, occasioned by a bruise a fortnight ago. Manyapplications had been made during this fortnight but the sore had nodisposition to heal. I applied the lunar caustic to form an adherenteschar. 

From this time the pain and inflammation subsided. The eschar remainedfirm and adherent, and in six days separated leaving the woundhealed. 

III. ON ULCERS. 

From the preceding observations it would naturally be concluded thatthe lunar caustic would afford a remedy for the treatment of ulcers. This conclusion is perfectly just. Yet there are many circumstanceswhich render the mode of treating ulcers by the caustic, efficaciousor the contrary. 

In order that the treatment by eschar may be successful, there must bethe following conditions in regard to the ulcer: first, the surfaceoccupied by the ulcer must not be too extensive; secondly, it mustnot be exposed to much motion or friction; and thirdly, it must not beattended by a profuse discharge; for all these circumstances have adirect effect in, preventing the formation of an adherent eschar or ofremoving it if formed. 

I observe, therefore, that I have not found the mode of treatment byeschar to succeed in large ulcers of the legs. But in small ulcers, and especially in those irritable and painful little ulcers which areso apt to form about the ankle and occasionally occur near, the tendoachillis, and in which Mr. Baynton's plan is inadmissible, the causticis invaluable; in these cases the cold poultice and lotion shouldprecede the application of the caustic, for a few days, that theirritability and inflammation of the sore and surrounding skin may befirst subdued; and after the eschar is formed, the part must be keptexposed to the air and defended from external injury, by enjoining thepatient to wear trowsers and to be careful not to disturb the eschar. 

The plan of curing ulcers is exactly what has been described in thetreatment by the unadherent eschar. For in these cases the eschar isgenerally unadherent at first. It is necessary therefore in all cases, except those of very small ulcers, to examine the eschar, making asmall puncture or rather smooth incision in its centre, so as toevacuate the subjacent fluid if there be any, taking great care not tobreak down or bruise the eschar so as to leave its inferior surface atall ragged. This operation should be repeated daily until the escharproves to be quite adherent. And if the ulcer be rather large, restshould be enjoined until the adherent eschar be fully and safelyformed, and a dose of saline purgative may be interposed. It must alsobe particularly borne in mind, that the eschar must be constantlydefended by the gold-beater's skin, which must be removed andreapplied at each examination. 

I have here spoken of ulcers upon the legs. But the same observationsapply 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 restduring 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 monthsduration, which are now in a healing state by the application ofcerate and poultice; the healing process is going on very slowly. These ulcers were caused by a fall which bruised the part but made nowound at the time; two small spots, which she compared to the pustulesof small-pox, formed, broke, and gave rise to the ulcers. I appliedthe lunar caustic to form eschars. 

At this time I had not begun to defend the eschar by the gold-beater'sskin, and in consequence both these eschars were torn by the patient'sstocking having adhered to them, and there was an oozing of fluid fromthe centre of each eschar on examination on the following day. I againapplied the lunar caustic. 

On the succeeding day, I found that the large eschar had again beendisturbed, the patient having applied a little linen, instead ofleaving it exposed. I reapplied the lunar caustic. 

On the next day both eschars were complete, but there was a littlefluid under the centre of each, which required to be evacuated by anincision. There was little inflammation or pain. 

On the following day, my patient expressed herself as astonished atthe rapid amendment. A little fluid was again evacuated from beneaththe centre of the eschar. 

On the next day the smaller eschar was quite adherent; under the largeone, there was still a very little fluid. 

About the ninth day, both the eschars were perfectly adherent. In twodays afterwards the eschars began to separate round the edges, and ina few days more, it was necessary to remove the separating portion bythe 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 theapplication of the caustic, and in a week was able to attend to herhousehold affairs. 

CASE XXII. 

J. Copeland, blacksmith, aged 38, came to me with many deepulcerations, from the size of a horse bean to that of a pea, attendedwith great pain, heat, itching and excoriations of the surroundingskin, obliging him to rest at different times, for several daystogether. These ulcers came without any apparent cause, have continuedfor many weeks, and have only been a little benefitted by rest, although he has applied many kinds of ointment, the last consisting ofequal parts of mercurial and of the tar ointment. I applied the lunarcaustic upon each ulcer, but not over the excoriation, and I enjoinedthe patient to leave the whole exposed to dry. 

On the following day, I was gratified to find that eschars had formedupon every ulcer; upon examination, a little fluid was found tosubsist under several of the larger eschars; this I evacuated, and Ithen applied the lunar caustic to the points from which it had issuedto make up the breach of continuity of the eschars over the surface ofthe ulcers. There was far less inflammation and scarcely any pain, andhe 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 againapplying the caustic. 

In four days after the last report, most of the eschars had separatedfrom the smallest ulcers leaving the parts healed. 

In a day or two more, my patient took cold and was affected withhoarseness and cough, and the skin round the eschar became excoriateda little. I directed a saline purgative and applied the lunar causticto the excoriated parts. 

On the succeeding day his cold was better and the eschars adherent. Idirected five grains of the Plummer's pill to be taken night andmorning, which he continued about a week. 

Five days after this period, I again observed a disposition toexcoriate. I applied the caustic. 

In two days more, the eschars were adherent, and there was no furtherappearance of excoriation. 

In ten more days, the eschars had separated and all the ulcers andexcoriations were completely healed. 

This case occurred several years ago, and there has been no return ofthe 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 longsubject to ulcers of the legs, and he had a similar ulcer to thepresent one in the same situation, some years ago, which provedextremely difficult to heal under usual remedies. The veins arevaricose. --From the small size of the ulcer, I applied the lunarcaustic and protected the eschar by the gold-beater's skin. 

On the following day, I found the eschar complete but unadherent bythe effusion of a little fluid; this I evacuated daily in the manneralready described, for about a fortnight, when the eschar becameadherent. 

During the progress of the cure a little excoriation formed round theeschar. I touched the parts with the caustic, and the eschar thusformed served to support that formerly made, and so to do good. Thewhole adhered until the sore was very nearly healed; but as it wassituated in a part greatly exposed, it was removed by accident. Thecaustic was again applied; fluid formed underneath the eschar asbefore and required evacuating thrice; but at length the escharadhered, and in due time separated leaving the ulcer quite healed. 

The same patient has since been affected by similar ulcers atdifferent times in different parts of the leg. He applied early andthey were each time easily cured by one application of the caustic. Hehas also twice had injuries upon the shin, which were readily cured inthe same manner. 

CASE XXIV. 

The following case must not be regarded as altogether trifling. Forsuch sores are very apt to spread and to remain long verytroublesome. 

An old gentleman came to me with an oblong ulcer on the shin about aninch in length; it was very painful and inflamed. I applied the lunarcaustic to form an eschar and requested him to call on the followingmorning. He did not come, however, but on seeing him the next day itwas requisite to evacuate a little fluid; this was repeated on theythird day, after which period the eschar remained adherent, and thepart 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 lunarcaustic over the ordinary modes of treatment in some ulcers of thelegs, and will, I trust, be found particularly interesting. 

Mr. G. B. Aged 60, a very tall and stout person, had two ulcers, one ofthe size of a shilling upon the back of the leg just above the tendoachillis, the other rather less, on the outside of the leg; they werecaused by his scratching the parts severely three months before; andhe had used various remedies in the interval. There were some oedemaof the leg to which he is subject, and much pain and inflammation ofthe ulcers. I directed the application of a cold poultice and lotion, and prescribed the pil. Hydrarg. Every second night with an aperientdraught the following morning. 

This plan of treatment was continued for a number of days without anyappearance of healing in the ulcers. As the inflammation had subsidedI proposed to adopt the mode of treatment recommended by Mr. Baynton, fearing that any attempt to heal the ulcers by eschar would fail onaccount of the oedema. This project was deferred, however, by thepatient's wish to try the effect of sea-bathing. After a month'sresidence on the sea shore I was, on the return of my patient, againrequested to examine these ulcers, which I found very nearly in thesame state as before, only with the addition of some excoriations. Irecommended the cold poultice for a few days to allay inflammation, and then tried Mr. Baynton's plan, dressing the leg myself daily; onthe fourth day, however, the sore above the tendo achillis became soirritable that I was compelled to desist and to remove the plaster andbandage, and I again directed the cold poultice with rest, for a fewdays. 

When the inflammation had again subsided, I ventured, notwithstandingthe oedema, to apply the lunar caustic to form an eschar, enjoiningrest and the horizontal position. 

On the following day complete but unadherent eschars were formed overeach sore. There, had been no pain after the smart of the caustic hadceased. On carefully making an incision into the centre of eacheschar, 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 thefourth, the patient having used his leg a little, rather more fluidwas evacuated from the centre, and there was rather more inflammationround 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; theeschar became adherent, and I allowed my patient to walk about. 

In about six weeks the eschar was nearly separated and I removed itby the scissors, leaving only a portion adherent of the size of apea. It had been prevented from being removed from the beginning, bythe gold-beater's skin. The smaller eschar had dropped off leaving theulcer quite healed. In a week more the last portion of escharseparated from the larger sore, leaving it also quite well. 

CASE XXVI. 

The following case occurred in the person of a lady with varicoseveins and far advanced in pregnancy. Its speedy cure by the causticwas, therefore, the more remarkable, and saved her much trouble andsuffering. 

Mrs. C. Aged 40, had two small irritable and inflamed ulcers, underthe inner ankle. I applied the lunar caustic to form an eschar. 

It was requisite to evacuate a little fluid from under the eschars forthree successive days; they then remained adherent. 

About the usual time the eschars separated, leaving a small point ofthe size of a pin's head, unhealed; this I again touched with thecaustic. The case required no further attention. 

This case leads me to caution my readers always to examine the partscarefully after the separation of the eschars, and if there be theslightest ulcer remaining to apply the caustic to it. 

CASE XXVII. 

Mrs. Wakefield, aged 36, had an extensive ulceration with excoriationon the upper part of the right breast, of two months continuance; ithad been greatly aggravated by improper treatment. I applied the lunarcaustic over the whole ulcerated and excoriated surface. It gave muchpain. 

On the following day I was concerned to find that part of the escharhad been separated by the patient's dress. I repeated the applicationof the caustic and again directed the part to be exposed and carefullyprotected from being disturbed. The breast required to be supportedbeing full of milk. 

On the succeeding day an adherent eschar existed over all theulcerated parts, and the pain, redness, and irritation had nearlysubsided. 

On the fourth day there was still less pain and inflammation. On theeight 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, andanother behind it of the size of a horse-bean; they have beenextremely troublesome and under surgical treatment for the last year, but during the last few weeks she has tried cerate, poultice, and thecold lotion. The leg is much swollen and inflamed, the rednessextending several inches round the wound and over the instep; theoedema increases towards night. She has been in the habit of takingsaline purgatives frequently. 

I directed my patient to continue the cold poultice and lotion, and torest completely for several days. At this period, the inflammationhaving somewhat abated, I applied the lunar caustic to form escharsand protected the parts with gold-beater's skin. 

On the following day there was a slight increase of redness round theeschars. Upon making an incision into their centre some fluid wasevacuated. The same report was made on each of the two followingdays. 

On the seventh day, the eschars having been neglected, fluid hadescaped from beneath the eschars at their edges, and my patientcomplained of more pain. A little more fluid escaped in the samemanner on the following day on making a little pressure upon theeschars. I applied the caustic to make up the breach. 

Subsequently to this day there was an increase of inflammation. Fromthis circumstance, and from the neglect of the eschars for two orthree days already mentioned, I suspected the formation of a scabunder them. It was impossible to pierce the eschars by the penknifewithout breaking them, as they had become too hard and thick by delayand the addition of the scab. 

I again directed the cold poultice for four or five days. On examiningthe wounds on the separation of the eschars, I found the healingprocess going on. I reapplied the lunar caustic to form eschars, and Ievacuated a little fluid from their centre for three successive days. 

At this time the patient took cold and a smart attack of fever cameon, and the part round the eschars became much inflamed. I prescribedan emetic and purge, and a cold poultice and lotion. 

In the space of a week I again attempted to form an eschar over thelarger wound, for the smaller one had quite healed. 

The next day I discharged a little fluid from the centre, and again onthe eight or nine succeeding days, giving saline purgatives. 

After this time the eschar remained adherent, and no further remedywas required. 

This case is particularly interesting and important, as it illustratesthe plans to be adopted in two circumstances of no unfrequentoccurrence; 1. When there is an attack of fever and increasedinflammation, and 2. When a scab forms underneath the eschar. In bothcases we must relinquish our attempt to form an adherent eschar for atime, --apply the poultice, --and recur to the caustic in the course ofa few days. 

In the beginning of my trials of the treatment of the ulcers by thecaustic, I was repeatedly betrayed by the smooth appearance of theeschar, to think that all was going on well, when in fact a scab wasall along forming underneath. In these cases inflammation soonfollowed, and it was only by carefully and daily evacuating the fluideffused under the eschar that I at length succeeded in effecting anadherent eschar free from surrounding inflammation. This remark cannotbe too often repeated. 

CASE XXIX. 

The peculiarity of the present case arose from neglect in evacuatingthe fluid effused under the eschar the day succeeding its formation, the consequence of which was that the edges of the eschar becameraised all round, without however being entirely detached. 

Mr. Draper, aged 50, had a small irritable ulcer of the size of ahorse-bean, upon the shin, of a month's duration, with surroundinginflammation to the extent of several inches. I applied the lunarcaustic 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 inone point of this ring by a penknife and evacuated the fluid, and Iagain applied the caustic all round in order to give firmness to theedges of the eschar. 

On the succeeding day an opening was made in the centre of the escharand a little more fluid was evacuated. 

This mode of treatment was continued daily for about a week, theinflammation gradually subsiding and the eschar becoming adherent andcorrugated. In about three weeks, the patient thinking the sore quitewell detached the eschar; there was still, however, a minute ulcerleft, which was touched with the caustic. 

CASE XXX. 

C. Cocking, aged 17, has an ulcer of the size of half-a-crown on theinner part of the knee, occasioned by an accident. He had been a monthunder surgical care in the country when he applied to me, but theulcer continued without disposition to heal, and fungous; it hadapparently been treated by a solution of sulphate of copper. I appliedthe lunar caustic over the surface of the sore and upon thesurrounding skin. 

On the following day, the eschar was unadherent and puffy, and onpiercing it a little fluid escaped. The incision into the eschar wasrepeated three or four successive days, but the eschar still retainedits puffy character; I therefore directed a poultice to be applied toremove it. 

In two days the eschar was separated leaving the ulcer with itsfungous appearance. I removed the fungous part by scissors, anddirected the poultice to be applied and to be continued for two days. I then formed another eschar. This required a daily puncture for theevacuation of subjacent fluid, for six days; it then remainedadherent, and in about a fortnight it separated leaving the ulceratedsurface healed. This patient was not at all confined. 

CASE XXXI. 

Mr. S. Aged 30, had a sore two inches in length in the groin, theremains of a phagedenic ulcer. It had remained stationary a wholefortnight under the ordinary treatment by bandage. I applied the lunarcaustic to form an eschar and then the gold-beater's skin. 

The day afterwards, I found the eschar incomplete and I applied thecaustic 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 andadherent. 

On the fourth following day, great part of the eschar had separatedleaving the ulcer healed, and I had no occasion to see the patientagain. 

IV. OF SOME ANOMALOUS CASES. 

1. _Of Whitlow. _

The lunar caustic is very useful in the treatment of this painfulaffection. Patients seldom apply to the surgeon before suppuration hastaken place. It is then, I think, the best plan to open the abscessfreely, to apply the caustic well within the cavity, and then toenvelope the part by the cold poultice and lotion. In this manner thepain and irritation are almost immediately removed, after the smart ofthe caustic has subsided. A second application is seldom necessary. In some cases, however, there is an increase of inflammation in a dayor two, which requires the caustic to be again applied. When theinflammation has subsided, the loose cuticle may be removed, and thecaustic must be applied to form an eschar. 

In slight cases the lunar caustic may be passed over the inflamedpart, and in this manner suppuration and the continuance ofinflammation is often prevented. 

In those cases in which the suppuration is artificial and attendedwith severe diffused inflammation, the pus should be evacuated and acold poultice applied for a day or two; for the too early applicationof the caustic would only add to this kind of inflammation; see p. 11;afterwards the skin may be removed, and if there be excoriations thecaustic may be lightly applied. 

2. _Of Inflammation of the Finger. _

The following case of inflammation of the finger occurred without anyassignable cause. 

CASE XXXI. 

A young man, aged 18, came to me with a painful swelling of themiddle finger of the right hand; suspecting deep-seated abscess, Imade a free incision and evacuated a little pus. I then applied thelunar caustic within the cavity and directed a cold poultice to beapplied 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 indexfinger, which issued in severe inflammation extending over the back ofthe hand. I made a free incision in the part first affected, evacuateda little pus, and directed a poultice to be applied. 

On the following day, there was less pain but still great swelling atthe back of the hand, which, I think, would have been removed had thecaustic 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 daysfrom 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 navelin infants which is difficult of cure in the ordinary way. I had onecase which had subsisted for two years, and another, which hadcontinued for two months, and were, during those periods, a source ofgreat 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 whenthe bleeding has quite ceased, the lunar caustic is to be applied, and the part defended by the gold-beater's skin and kept carefullyfrom any moisture. 

In one of the cases mentioned above the eschar was accidentallyseparated twice and required to be renewed; but both cases were curedin 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 isfrequently extremely troublesome. 

In one case suppuration of the integuments took place in the forepartof the knee, and the patient was obliged to leave her situation and goto her friends at a distance, although every antiphlogistic means wastried for her relief. 

In two other cases, after the application of twenty leeches and theadministration of an emetic and purgative medicine, I applied thelunar caustic freely over the whole surface of the knee previouslymoistened with water. In a few hours the cuticle was raised andvesicated; I evacuated a viscid puriform fluid, and I directed theconstant application of the cold poultice and lotion. 

In a few days all inflammation subsided and the patients remainedwell. 

These three cases having occurred to me at the same time, and beingapparently equally severe, I was enabled to judge of the efficacy ofthis use of the caustic, and I can strongly recommend it to a futureand 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 causticin other cases of inflammation, in which a more than usually activelocal remedy is required. 

5. _Of Tinea Capitis, &c. _

In this place I have only to observe that I have in some casescompletely succeeded, in others completely failed, in the cure oftinea capitis, by the lunar caustic. As I have not hithertodistinguished these cases from each other; and as I could only offerconjectures on the subject, I think it best to leave it for futureinquiry. 

The same observation applies to some other cutaneous affections whichI 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 thelunar caustic as an infallible remedy for all local diseases. I amquite aware of the propensity, in recommending a favourite remedy, toextend its use beyond its true limits. The caustic, like all otherremedies, requires to be employed with discrimination; and it istherefore my object in this little work, to state in which cases itis, and in which cases it is not, useful and successful. 

With this object, I have thought it not improper to add, in aconcluding chapter, some observations on those cases in which I havefound the lunar caustic to be inadmissible. It will, at the same time, be found that such cases, in the course of their treatment by theordinary measures, not unfrequently become fit cases for theapplication of the caustic, with the view of more speedily completingthe cure. 

This observation is particularly applicable to the cases of burns, oflarge ulcers, of fungous ulcers, &c. 

The caustic is inapplicable in extensive lacerations, for the samereason that it is so in extensive ulcers. 

I have found the caustic of little use in incised wounds, and shouldnot employ it except in such wounds received in dissection. 

I have failed in my attempts to heal scrofulous sores by the adherenteschar; I would propose the trial with the lunar caustic and poultice. 

In erysipelatous inflammation, where vesicles are formed, the causticdoes 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, hasalways appeared to me to increase the inflammation and vesication, even inducing blisters where there were none before. The caustic mustnot, therefore, be applied in these cases, until the inflammation hasentirely subsided; but when there remains only a small superficialulceration, the caustic may be passed lightly over the ulceratedsurface to form an eschar which is to be defended by the gold-beater'sskin; for the affection is then reduced to the state of a commonsuperficial ulcer. An adherent eschar is generally readily formed, andno further application is required. If the ulceration be moreextensive and deeper, the lunar caustic may be applied, and the eschartreated, 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 treatedit with the ordinary remedies. There remained a superficialulceration of the size of half-a-crown. I applied the lunar causticlightly 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 daysmore it dropped off leaving the ulcer quite healed. 

CASE XXXIV. 

Mr. C. Aged 51, scalded his leg ten days ago on the instep. He appliedointments and poultices. The surface remained ulcerated to the extentof three inches in length and an inch and a half in breadth, andpresented a considerable thick slough in the centre; the inflammationcontinued to be considerable with some oedema towards the toes. Insuch a case I should now recommend a cold poultice to be applied forseveral days; but the present case occurring early in my trials of thecaustic, the latter remedy was applied forthwith over both the ulcerand slough. 

On the following day I learnt that the pain after the application ofthe caustic had been considerable for two hours. It then ceased andthe eschar became complete; and there was rather less inflammationand swelling. The patient had kept in bed. I prescribed a pill withthe hydrarg. Submurias, to be followed by an aperient draught. 

On the succeeding day my patient went down stairs and disturbed theeschar, and experienced more pain. The inflammation and swelling werestill less. I applied the caustic to the parts of the ulcer exposed bythe injury done to the eschar. 

During the two following days the inflammation subsided entirely; Ievacuated a little fluid from beneath the eschar. 

On the next day the eschar appeared adherent, except in the centrewhich was occupied by the slough. 

On the succeeding day, I evacuated a little fluid from beneath theslough. 

On the next day I removed the slough entirely by means of a pair ofscissors. The subjacent ulcer had a healthy granulated appearance. Iapplied the lunar caustic to it to form an eschar. 

From this time it was necessary to evacuate a little fluid from underthe eschar for ten successive days. It then became adherent, and inabout a fortnight it separated, leaving the ulcer healed. 

CASE XXXV. 

The following case will present a specimen of my trials of the lunarcaustic in larger ulcers. 

Anthony Knowles, aged 44, was kicked by a horse on the leg, above theinner ankle, two years ago. The part has never healed, but stillremains in the state of an open ulcer, attended by some inflammation. When I first saw this ulcer it was about two inches in diameter andnearly circular, with high edges, a surface of a greenish colour, andwithout any healthy granulations. I applied the lunar caustic to forman eschar. 

The pain from the caustic was severe for several hours. An eschar hadformed round the edges, but in the middle part it was quite wanting;the inflammation surrounding the ulcer had abated, and the green hueof its surface had disappeared. I reapplied the caustic in the centralpart. 

On the following day the eschar appeared tolerably complete in thecentre but had separated at one part of the circumference. I againapplied the caustic to the defective part. 

On the following day the eschar was defective in several parts, butthe inflammation was quite removed, there was no pain, and there hadbeen less smarting after each successive application of the caustic. Iagain 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 nomeans complete; some part of it was in a detached state. I removedthe loose portions and repeated the application of the caustic. 

This sort of treatment was continued for a fortnight without my beingable to effect the formation of a complete eschar. I thereforerelinquished the idea of healing the ulcer by the adherent eschar; Ieventually succeeded in doing so by applying the caustic every thirdday and the poultice continually, and I had hopes that the cure mightbe permanent, but he made application to me in two years afterwardswith a similar ulcer on the same part. 

In another similar case, I removed the elevated hard edges of theulcer by the lancet, and then tried the caustic, without bettersuccess. 

CASE XXXVI. 

The last case I have to give is one of great interest, as it clearlyshows the influence of the lunar caustic in subduing the inflammationsurrounding ulcerations, and in promoting the healing process, even incases of phagedenic ulcer. In such cases its influence eminentlydeserves a still further trial. 

Mrs. H. Aged 56, has had very extensive phagedenic ulcerations on thelegs and thighs during three years, which began in little red spotsand then spread rapidly, destroying the integuments. One of theseulcers, on the thigh, was twelve inches in length and five in breadth, and exhibited the appearance of a deep corroding furrow; it wassurrounded by a fiery redness and was attended by extreme pain. Therewere many other ulcers of the same kind, several nearly of the samemagnitude; and the poor patient was compelled to take large doses oflaudanum several times in the day. She had formerly been treated forsyphilis, and had afterwards taken the sarsaparilla freely; amongst agreat variety of local applications, the white bread poultice hadafforded most relief. 

I applied the lunar caustic to two of the smaller ulcers. 

On the following day the eschars were complete. I applied the causticto the large sore above described to the extent of three inchessquare, avoiding its application on the inflamed skin. 

On the next day I found the eschar last made complete, and I passedthe caustic over the ulcer to the extent of three inches more. 

On the succeeding day, the eschar was complete, adherent at thoseedges which adjoined the cuticle, and floating at the other edges overthe ulcer, and in the latter part allowing the escape of matter; roundthe adherent edges of the eschar the inflammation had entirelydisappeared, while it remained fiery as before round every other partof the ulcer. 

I continued my trials with the caustic in this case, but it gave somuch pain, and I had so little hope of final success, that Ialtogether relinquished the attempt to treat these ulcers by eschar. Some of the small ulcers were healed, however, and the larger oneassumed a more healthy character wherever the caustic had beenapplied. It may, therefore, remain a question whether the lunarcaustic may not still prove useful in phagedenic ulcers of a smallersize. 

FINIS. 

T. Wheelhouse, Printer, Nottingham. 

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