NOTES ON THE USE OF POULTICES.
BY GEORGE W. CALLENDER,| Assistant-Surgeon to St. Bartholomew’s Hospital.
Attention is at present attracted to various applications having for their object the better healing of wounds and sores of different kinds; but I should be sorry if, in the search after new, one at least of the ancient remedies should fall into disfavour. It has been asserted that poultices are often used to conceal defects of treatment, a kind of refuge in ignorance of any more advantageous applications, and that they often do positive harm by inciting profuse, and consequently exhausting, suppuration, and, no doubt, it is true they favour the tendency to suppuration which may exist in particular instances, and that they will increase a suppurating discharge when the latter is already established.
Most remarkable results, however, follow the use of poultices in certain cases—of lupus, for example. A woman attends at my out-patient room with ordinary lupus which, when first seen, had eaten away the middle portion of the upper lip, and had encroached upon the septum of the nose. A bread poultice was applied day and night to the ulcerated surface, and she took iodide of potassium. The sore was soon and completely healed. After six months she returned with the disease worse than ever, but it quickly healed again under treatment, and would, I am sure, remain well if she were ordinarily watchful over it. As the iodide of potassium may have had some influence in this instance, its use was dispensed with in other cases. A woman was taken into Sitwell ward with extensive lupus of the nose. It was with difficulty we persuaded her to submit to such simple treatment as the application of bread poultices continuously to the sore; she craved for physic, which was denied her. Very quickly the sore healed, and she left well. It is needless to record other and similar cases which have been treated in this simple fashion with the same satisfactory results.
Some months ago a man was sent to me from Woolwich with an ulcer on the outer angle of the orbit extending to the conjunctival surfaces of the lids; it was irregularly scabbed over. In my opinion, and in this I was confirmed by several of my colleagues, it was an example of so-called epithelial disease; at all events it had been an open and increasing sore for nearly five years, and before proceeding to remove it I agreed to try the effect of some local caustic. To clean the surface a bread poultice was applied, and it mended so much that this application was continued, when great part of the sore healed rapidly, and the remainder cicatrized after being touched with caustic zinc.
All surgeons are familiar with the good results which follow the application of a poultice to an acutely inflamed surface-part. Quite recently a woman has been under my care with inflammation of the tissues about the internal saphenous vein. She has progressed quite well towards convalescence by keeping the limb at rest, and by having the inflamed vein-track covered with a large poultice of linseed meal; no other treatment has been required. It is a common fault, not so much perhaps in hospital as in private practice, not to give a poultice the chance of curing a local inflammation by limiting its application to the part affected. A poultice to be of any use should widely cover the tissues which surround the seat of inflammation; for example, if the hand is inflamed the poultice should not only completely envelope it, but should extend at least half-way up the fore-arm: and this rule holds good especially when poultices are used for superficial or for subcutaneous diffused inflammation.
A little girl I saw recently in Sitwell ward had a fierce attack of inflammation, after measles, which involved one side of her face and neck. As it threatened to lead to suppuration we made three punctures, carried deeply amongst the tissues, and then applied a succession of large poultices to the entire of the affected side. In twenty-four hours the child, from a condition of great depression, was well enough to leave the hospital—the swelling was much reduced, probably by the draining away of serous fluid, but no suppuration was established. I often direct a bubo to be punctured with a grooved needle, the needle being carried across so as to make a double opening; poultices are then applied, and if the parts are moderately rested, the swelling will usually subside; if the bubo is suppurating the same treatment will suffice to evacuate the pus, and this having discharged the bubo disappears, and no trace even remains of the openings through which the pus has passed out. In cases such as those referred to, some without, some with a surface lesion, the mischief is remedied without any suppurative action being set up by the use of the poultices.
It is desirable, when there is much discharge into a poultice, to dust over the skin about the openings whence the discharge issues some oxide of zinc, or some other drying powder; if this precaution is not taken the matter will irritate and probably enlarge the opening, or will produce vesicles, which break and leave excoriations, or painful papulæ on the adjacent integument. It should be remembered also that great heat is not needed with the poultice; it should be comfortably warm to the patient, and should never be allowed to get, by comparison with its condition when applied, so cold as to lessen the temperature of the part.
Ulcers of many kinds will heal rapidly when treated with poultices; and when I use the word “rapidly,” I refer to comparative quickness of healing, as ascertained by measuring the chief diameters of the ulcerated surfaces; their progressive over-closing is thus very accurately checked from week to week. This refers more especially to ordinary ulcers, such as result from injuries. A boy now attends in my out-patient room who under this treatment is healing up a sore on the fore-arm, the remains of a bad crushing of the part. Sometimes this healing is hastened by dusting the ulcer twice daily with powder of oxide of zinc before the poultice is at such times applied. In Sitwell ward a woman is just well of a severe phagedænic sore involving the skin over and below the knee. Mr. Cumberbatch, the dresser of the case, kept the parts at rest by swinging the limb, and applied at first an ordinary linseed poultice, then warm water dressing (another form of poultice), and, to expedite the healing of a few remaining sores, some resin ointment. The cure has occupied twenty-six days, a very rapid progress considering the constitutional nature of the affection: no medicine was needed.
I never could understand, seeing it is desirable to keep the parts immediately after an operation warm and quiet, why those objects should not be attained by the use of poultices; nothing I know of is more efficient to lessen the trouble caused by the starting of a limb after amputation, than the weight of and the resistance offered by a large poultice surrounding the stump. But their employment is in disfavour, first from the fear of their provoking recurrent bleeding, although this reckons for little if due care has been taken to have the wound thoroughly dry before closing it, and unless this care is taken there is little chance of its uniting by the first intention; secondly, by the prevailing notion that such union is prevented by the relaxing influence of this kind of dressing. Wishing to put this to the test of experience, the following cases, amongst others, were placed under treatment.
Having occasion to remove the larger portion of the left upper jaw of a female, about forty years of age, I brought together the incised wound of the face with wire sutures, and directed a bread poultice to be at once applied and renewed at intervals. The entire wound united by the first intention. A boy had his hand and fore-arm crushed by machinery, and it was necessary to perform amputation below the elbow. The flaps of integument were carefully adjusted, and the stump was poulticed. On the ulnar side the tissues united without suppuration; on the radial a portion of skin sloughed in consequence of the hurt it had sustained at the time of the accident, and on this side consequently the repair was less quickly completed. I recently amputated at the thigh, on account of strumous disease of the left knee of a boy, and brought the flap surfaces into apposition. The wound was at once covered with a linseed meal poultice. The next day, the stump being swollen, the wire sutures were cut. Bread poultices, and then warm water dressings, were afterwards employed, and the wound healed without any suppuration having been set up by the action of the local remedies. What pus did form was no more than might have been expected from incomplete primary union of portions of the cut surfaces.
I should like to see a more extended trial given to applications which keep a wound warm and moist continuously from the time of the operation. I think their use would give satisfactory results. No doubt they are most serviceable remedies throughout various forms of ulceration, and especially so in cases of lupus.
THE HYPODERMIC INJECTION OF MORPHIA IN MENTAL DISEASE: A CLINICAL NOTE.[[7]]
BY C. LOCKHART ROBERTSON, M.D. CANTAB., F.R.C.P.
Medical Superintendent of the Sussex Lunatic Asylum, Hayward’s Heath.
In the first number of the Practitioner, July 1868, Dr. Anstie has published a Paper on “The Hypodermic Injection of Remedies,” in which he truly says, that despite the satisfactory working of the method and of the greatly increased power in handling remedies which it gives us, it is still very much unappreciated. Believing that this remark applies even to the employment of the hypodermic injection of morphia in the treatment of mental disease, I venture on this occasion to lay before the Medico-Psychological Association in the half-hour we devote to Clinical Discussion, a brief outline of three successful cases illustrating the treatment by the hypodermic injection of morphia in recent mania, chronic mania, and melancholia respectively.
In October 1861 Dr. W. C. Mackintosh published a Paper in the Journal of Mental Science on “The Subcutaneous Injection of Morphia in Insanity,” which first drew my attention to this method of treatment. In the Reports of the Somerset Asylum, Dr. Boyd has also recorded his opinion of the value of this treatment in cases of maniacal excitement with sleeplessness, and in that form of destructive mania accompanied with dirty habits.[[8]]
The detail of the hypodermic method of treatment is carefully stated in Dr. Anstie’s Paper, and to this I must refer those who desire farther information regarding it. I use a solution of 6 gr. of the acetate of morphia to the drachm; Dr. Anstie’s strength is 5 gr. I always commence with ♏︎v of the solution (½ gr.), and in only one case out of many hundred hypodermic injections of morphia has any injurious effects followed the remedy thus used.
Case I. Recent Mania.—J. H. W., No. 1,563, female, aged 20, single; domestic servant. Form of disease, acute asthenic mania.
History.—Never had any previous attack. No history of insanity in her family. Has been engaged for some years as a domestic servant. No reason can be given for her illness. It is stated that for the last three or four months she has been strange, and at times depressed, and that about three weeks ago she suddenly became maniacal, and has remained in a state of violent excitement ever since.
Progress.—On admission at Hayward’s Heath, on the 22d of March last, she was in a state of the most intense maniacal excitement, and very incoherent. Physically, she was suffering from marked typhoidal symptoms, her pulse was feeble and very rapid, her skin dry and harsh, her lips and teeth covered with sordes, her tongue coated with a thick creamy fur. She refused all food, and had had no sleep for several nights.
Although she could not be prevailed on to take any solid food, she was coaxed at times during the first two days after her admission to take ½ gr. of morphia in a little brandy, but she was almost invariably sick after it; moreover, the excitement continued, and she could obtain no sleep.
On the third day the hypodermic injection of ½ gr. of morphia was commenced, and continued every four hours except during the middle of the night. On the fifth day she was calm, although incoherent, and had slept during the whole of the previous night, took her food well, and had lost nearly all the typhoidal symptoms. Moreover, the irritability of the stomach was completely allayed.
She has since then recovered without a bad symptom, and she is now convalescent.
This case showed in a very marked manner the advantage of the hypodermic injection of morphia over its administration by the mouth in cases, which so frequently occur, of acute mania with marked asthenia and irritability of the stomach, causing refusal of food.
Case II. Chronic Mania.—W. H., No. 950, aged 68, single, groom. Form of disease, chronic mania, characterised by frequent recurrent attacks of maniacal excitement.
History.—Strong hereditary taint of insanity. Nearly all his brothers and sisters are more or less insane or eccentric. Much given to habits of intemperance, but, although often strange and eccentric, was never sufficiently insane to warrant his being placed in a lunatic asylum until he was 64 years of age, when he was attacked with acute mania and removed to Hayward’s Heath.
Progress.—During the attack of mania under which he was suffering when admitted into the asylum he was treated with small doses (♏︎x) of tincture of digitalis every four hours. The symptoms lasted for nearly three months. He was then calm for many weeks. On the next outbreak of mania, equal parts of liq. opii were added to the digitalis, and with a beneficial effect, the attack not lasting so long.
He was thus treated for some two or three years. He generally suffered from three or four attacks in each year.
In April 1868 he had an unusually severe attack of excitement, combined with much noise and destruction of clothing. The usual medicines having no effect, he was treated with the subcutaneous injection of morphia (½ gr.) three or four times in the twenty-four hours, and with marked benefit.
On the recurrence of the next attack subcutaneous injection was had recourse to at once, and the period of excitement was reduced to little over a fortnight.
The next attack passed off in an equally satisfactory manner. In the January of the present year an attack of recurrent mania being evidently imminent, the old treatment of digitalis and opium was tried for fully a fortnight, but without benefit. On February 8th ½ gr. of morphia was injected, and the injection continued every six hours, and on February 10th (to quote from the case-book) he was decidedly improved and free from excitement and noise.
Not only, therefore, is the duration of the attack of recurrent mania diminished in this case, but during the attack the excitement is much less intense under the hypodermic method of treatment.
Case III. Melancholia.—M. T., No. 1,397, female, aged 57, married, domestic servant. Form of disease, acute recurrent melancholia.
History.—No hereditary taint of insanity. Has been insane and confined in asylums three or four times. She is temperate in her habits, and her attacks of insanity appear to have followed on most occasions the puerperal condition, but the present illness is stated to be due to family troubles.
Progress.—On admission she was suffering from the most acute type of melancholia, combined with insomnia, refusal of food, and a strong suicidal tendency. Moreover she was in a poor physical condition, having lost much in weight, and being thin and anæmic.
In the first place she was treated with stimulants, sedatives, and a nourishing diet, but she remained from May 14th, the day of admission, until May 20th, without any improvement, and was becoming so reduced, from want of sleep and constant worry, that her life was despaired of. On the 20th May, 1868 (to quote from the case-book), “she passed a very restless night, and is much exhausted this morning: injected acetate of morphia gr. j, and she soon fell asleep; took her food well on awaking.”
On the 23d, “injected gr. j of morphia twice daily since the last entry, and with decided benefit, and she is much less excited. Sleeps well, and the suicidal tendency seems to have passed away.”
On July 15th the entry is as follows:—“Has improved uninterruptedly ever since the last entry, and is now tolerably sane.”
She was discharged recovered on 7th December, 1868, and has continued sane to this date, although in such a case another relapse is most probable.