ON HEALING BY ESCHAR.

Having been led, by several circumstances, to try the effects of the Lunar Caustic in the treatment of Wounds and Ulcers, and having great reason, from these trials, to think that this remedy may be used with much advantage far more extensively than has hitherto been done, I lay the results of my experience before my medical brethren.

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

I. ON THE ADHERENT ESCHAR.

It appears scarcely necessary to describe the immediate and well known effects of the application of the lunar caustic to the surface of a wound or ulcer. It may, however, be shortly observed that the contact of the caustic induces, at first, a white film or eschar which, when exposed to the air, assumes in a few hours a darker colour, and at a later period, becomes black; as the eschar undergoes these changes of colour it gradually becomes harder and resembles a bit of sticking plaster; in the course of a few days, according to the size and state of the wound, the eschar becomes corrugated and begins to separate at its edges, and at length peels off altogether, leaving the surface of the sore underneath, in a healed state.

In the formation of this eschar several things require particular attention. The application of the caustic should be made over the whole surface of the sore; and indeed no part requires so much attention as the edges; to make a firmer eschar the caustic should even be applied beyond the edge of the wound, upon the surrounding skin, for the eschar in drying is apt to contract a little, and in this manner may leave a space between its edges and that of the adjacent healthy skin.

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

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

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

To the surface of the wound the eschar supplies a complete protection and defence, and allows the healing process to go on underneath uninterruptedly and undisturbed. It renders all applications, such as plasters, totally unnecessary, as well as the repeated dressings to which recourse is usually had in such cases; and it at once removes the soreness necessarily attendant on an ulcerated surface being exposed to the open air. In many cases too, in which the patients are usually rendered incapable of following their wonted avocations, this mode of treatment saves them from an inconvenience, which is, to some, of no trifling nature.

It has already been stated how important it is that the eschar should be preserved adherent. To secure this still more effectually, I have found it of great utility to protect it by a portion of gold-beater’s skin. The skin surrounding the wound is simply moistened with a drop of water, and the gold-beater’s skin is then to be applied over it and over the eschar, to which it soon adheres firmly, but from which it may be removed at any time, by again moistening it for a moment with water; the same bit of gold-beater’s skin admits of being again and again reapplied in the same manner.

The other circumstances which render the eschar unadherent will be mentioned hereafter. In the mean time the fact stated , will sufficiently establish the propriety of treating distinctly of the adherent eschar.

I now proceed to mention some other effects of the application of the caustic. The first is that, in cases in which there would be much and long continued irritability and pain, as in superficial wounds along the shin, all this suffering, and its consequences in disabling the patient, are completely avoided. A blush of inflammation forms around the eschar, but this gradually subsides without any disagreeable consequences, and the inflammation which would otherwise have been set up is entirely prevented by the due formation of the eschar.

If inflammation be previously established, it is increased, at first, by the application of the caustic. But if this inflammation be not severe, and if the eschar remain adherent, all inflammation, both that induced by the application of the caustic, and that existing previously, entirely subsides. When the previous inflammation round the ulcer is considerable, however, the application of the caustic would induce vesication, and it should in such a case of course be avoided, and another mode of treatment to be described hereafter must be adopted.

I would introduce in this place some observations on the comparative effects of healing by eschar and by scabbing. On the subject of scabbing I must refer my reader to the well known work of Mr. John Hunter. The advantage of healing by eschar over that by scabbing is quite decided. By comparative trials, I have found that whilst the scab is irritable and painful, and surrounded by a ring of inflammation, the adherent eschar is totally free from pain and inflammation; and that whilst the scab remains attended by inflammation and unhealed, the eschar is gradually separating, leaving the surface underneath completely healed. To these observations I may add that the success of the plan of healing by eschar is infinitely more certain as well as more speedy than that by scabbing.

I shall, in conclusion, briefly recapitulate the advantages of this mode of treatment. In the first place, it will be found far more efficacious and speedy than any other; secondly, it has the great advantage of saving the patient much suffering and inconvenience; and thirdly, it renders the repeated application of dressings and ointments quite unnecessary. Its utility is extremely great, therefore, where the time of the poor, the expense of an establishment, and the labours of the medical officer, as well as the sufferings of the patient, require to be considered; and it will I imagine be found of no little advantage, in all these respects, in many cases which are incident to the soldier and sailor.

II. ON THE UNADHERENT ESCHAR.

The eschar is generally adherent in cases of recent injuries, and in small ulcers, when they are nearly even with the skin and attended by little inflammation. In other cases the eschar is too apt to be unadherent, and this arises from the formation of pus or of a scab underneath.

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

When a scab forms underneath the eschar, which does not happen except the fluid has been allowed to remain too long under the eschar without being evacuated, there are pain and some inflammation, the eschar does not separate, but remains long over the sore, and there is no appearance of healing.

When it is ascertained that there is fluid underneath the eschar, a slight puncture is to be made by the point of a penknife, the fluid is to be gently pressed out, and the caustic is then to be applied to the orifice thus made. The same plan is to be adopted if the fluid ooze out at the edge of the eschar; it is to be fully evacuated by pressure, and the orifice is to be touched with the caustic. The healing process goes on best however when the orifice is in the centre of the eschar. After this treatment the eschar occasionally remains adherent, but more frequently the fluid requires to be evacuated repeatedly, and this should be done every twelve hours, or once a day, according to the quantity of fluid formed, taking care that the eschar be not needlessly separated by allowing the fluid to accumulate underneath. If, from accident, the eschar is separated before the sore be healed I would reapply the caustic. At length the eschar becomes adherent, and in due time begins to peel off, leaving the surface healed.

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

The gold-beater’s skin is more useful as a protection to the unadherent than to the adherent eschar, as the former would be more liable to be torn off by accident than the latter. The gold-beater’s skin must be removed in the manner already described, whenever the subjacent fluid is to be evacuated, and must be reapplied after touching the orifice with caustic.

The pain experienced on the application of the caustic is greater or less according to the sensibility and size of the wound. In small wounds it is trifling, and of short duration; it is more severe in recent wounds than in ulcers; it soon subsides in every case, and then the patient enjoys greater ease than would be experienced under any other mode of treatment. Little or no pain is caused on applying the caustic after evacuating the subjacent fluid of an unadherent eschar. Altogether the pain inflicted by the caustic is far less than is generally imagined, and forms scarcely an obstacle to its employment.

It may be proper, in this place, to notice such circumstances as render the employment of the caustic improper or inefficient. It is improper to employ the caustic when the ulcer is too large to admit of the formation of a complete eschar; or when it is so situated as to render it impossible that the eschar should remain undisturbed, as between the toes, unless, indeed, the patient be confined to his bed; or in cases attended by much inflammation, or by much oedema.

I have found no kind of caustic so manageable as the lunar caustic; and this is best applied in the solid form. I have thought too, that the newly prepared lunar caustic is more apt to dissolve on being applied than that which has been longer made and more exposed to the air; the latter is therefore to be preferred.

III. ON THE TREATMENT BY ESCHAR AND POULTICE.

In many cases in which it is impossible to adopt either the mode of treatment by the adherent or the unadherent eschar, it is of great utility to apply the caustic first and then a cold poultice made without lard or oil: this plan is particularly useful in cases of punctured wounds attended by much pain and swelling, and in cases of recently opened abscesses. By this application the pain and swelling are much subdued and a free issue is secured for the secreted fluid; and in no case have I seen the original inflammation increased by it.

It is generally necessary to repeat the application of the caustic every second or third day, or every day if the inflammation and swelling of the part be considerable, and the cold poultice may be renewed about every eight hours. At length, however, the inflammation having subsided, the attempt may be made to form an adherent eschar.

I have seen many cases, in which, by this mode of treatment, much suffering and perhaps the loss of some of the smaller joints have been prevented, particularly cases of deep seated inflammation of the fingers, which, having been neglected, have issued in severe inflammation, abscess, and terrible fungous growths. In these cases it is not only necessary to apply the caustic to the surface of the sore, but in every cavity or orifice which may be formed by the disease.