OF SOME CASES IN WHICH THE CAUSTIC IS INAPPLICABLE.

It is by no means my intention to recommend the application of the lunar caustic as an infallible remedy for all local diseases. I am quite aware of the propensity, in recommending a favourite remedy, to extend its use beyond its true limits. The caustic, like all other remedies, requires to be employed with discrimination; and it is therefore my object in this little work, to state in which cases it is, and in which cases it is not, useful and successful.

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

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

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

I have found the caustic of little use in incised wounds, and should not employ it except in such wounds received in dissection.

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

In erysipelatous inflammation, where vesicles are formed, the caustic does injury, as in recent burns.

I have always found that the caustic has done injury in boils, aggravating rather than diminishing the affection.

1. Of Burns.

The application of the lunar caustic in recent burns or scalds, has always appeared to me to increase the inflammation and vesication, even inducing blisters where there were none before. The caustic must not, therefore, be applied in these cases, until the inflammation has entirely subsided; but when there remains only a small superficial ulceration, the caustic may be passed lightly over the ulcerated surface to form an eschar which is to be defended by the gold-beater’s skin; for the affection is then reduced to the state of a common superficial ulcer. An adherent eschar is generally readily formed, and no further application is required. If the ulceration be more extensive and deeper, the lunar caustic may be applied, and the eschar treated, exactly as in common ulcers.

It may be well to illustrate these points, by the following cases.

CASE XXXIII.

A little girl, aged 10, scalded her breast a week ago and has treated it with the ordinary remedies. There remained a superficial ulceration of the size of half-a-crown. I applied the lunar caustic lightly over the surface of the sore, and then the gold-beater’s skin.

On the following day, an adherent eschar had formed, and in five days more it dropped off leaving the ulcer quite healed.

CASE XXXIV.

Mr. C. aged 51, scalded his leg ten days ago on the instep. He applied ointments and poultices. The surface remained ulcerated to the extent of three inches in length and an inch and a half in breadth, and presented a considerable thick slough in the centre; the inflammation continued to be considerable with some oedema towards the toes. In such a case I should now recommend a cold poultice to be applied for several days; but the present case occurring early in my trials of the caustic, the latter remedy was applied forthwith over both the ulcer and slough.

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

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

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

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

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

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

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

CASE XXXV.

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

Anthony Knowles, aged 44, was kicked by a horse on the leg, above the inner ankle, two years ago. The part has never healed, but still remains in the state of an open ulcer, attended by some inflammation. When I first saw this ulcer it was about two inches in diameter and nearly circular, with high edges, a surface of a greenish colour, and without any healthy granulations. I applied the lunar caustic to form an eschar.

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

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

On the following day the eschar was defective in several parts, but the inflammation was quite removed, there was no pain, and there had been less smarting after each successive application of the caustic. I again applied the caustic.

On the succeeding day, I learnt that my patient had been intoxicated, and I found the ulcer attended by inflammation. The eschar was by no means complete; some part of it was in a detached state. I removed the loose portions and repeated the application of the caustic.

This sort of treatment was continued for a fortnight without my being able to effect the formation of a complete eschar. I therefore relinquished the idea of healing the ulcer by the adherent eschar; I eventually succeeded in doing so by applying the caustic every third day and the poultice continually, and I had hopes that the cure might be permanent, but he made application to me in two years afterwards with a similar ulcer on the same part.

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

CASE XXXVI.

The last case I have to give is one of great interest, as it clearly shows the influence of the lunar caustic in subduing the inflammation surrounding ulcerations, and in promoting the healing process, even in cases of phagedenic ulcer. In such cases its influence eminently deserves a still further trial.

Mrs. H. aged 56, has had very extensive phagedenic ulcerations on the legs and thighs during three years, which began in little red spots and then spread rapidly, destroying the integuments. One of these ulcers, on the thigh, was twelve inches in length and five in breadth, and exhibited the appearance of a deep corroding furrow; it was surrounded by a fiery redness and was attended by extreme pain. There were many other ulcers of the same kind, several nearly of the same magnitude; and the poor patient was compelled to take large doses of laudanum several times in the day. She had formerly been treated for syphilis, and had afterwards taken the sarsaparilla freely; amongst a great variety of local applications, the white bread poultice had afforded most relief.

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

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

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

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

I continued my trials with the caustic in this case, but it gave so much pain, and I had so little hope of final success, that I altogether relinquished the attempt to treat these ulcers by eschar. Some of the small ulcers were healed, however, and the larger one assumed a more healthy character wherever the caustic had been applied. It may, therefore, remain a question whether the lunar caustic may not still prove useful in phagedenic ulcers of a smaller size.