III. ON ULCERS.
From the preceding observations it would naturally be concluded that the lunar caustic would afford a remedy for the treatment of ulcers. This conclusion is perfectly just. Yet there are many circumstances which render the mode of treating ulcers by the caustic, efficacious or the contrary.
In order that the treatment by eschar may be successful, there must be the following conditions in regard to the ulcer: first, the surface occupied by the ulcer must not be too extensive; secondly, it must not be exposed to much motion or friction; and thirdly, it must not be attended by a profuse discharge; for all these circumstances have a direct effect in, preventing the formation of an adherent eschar or of removing it if formed.
I observe, therefore, that I have not found the mode of treatment by eschar to succeed in large ulcers of the legs. But in small ulcers, and especially in those irritable and painful little ulcers which are so apt to form about the ankle and occasionally occur near, the tendo achillis, and in which Mr. Baynton's plan is inadmissible, the caustic is invaluable; in these cases the cold poultice and lotion should precede the application of the caustic, for a few days, that the irritability and inflammation of the sore and surrounding skin may be first subdued; and after the eschar is formed, the part must be kept exposed to the air and defended from external injury, by enjoining the patient to wear trowsers and to be careful not to disturb the eschar.
The plan of curing ulcers is exactly what has been described in the treatment by the unadherent eschar. For in these cases the eschar is generally unadherent at first. It is necessary therefore in all cases, except those of very small ulcers, to examine the eschar, making a small puncture or rather smooth incision in its centre, so as to evacuate the subjacent fluid if there be any, taking great care not to break down or bruise the eschar so as to leave its inferior surface at all ragged. This operation should be repeated daily until the eschar proves to be quite adherent. And if the ulcer be rather large, rest should be enjoined until the adherent eschar be fully and safely formed, and a dose of saline purgative may be interposed. It must also be particularly borne in mind, that the eschar must be constantly defended by the gold-beater's skin, which must be removed and reapplied at each examination.
I have here spoken of ulcers upon the legs. But the same observations apply 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 rest during 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 months duration, which are now in a healing state by the application of cerate and poultice; the healing process is going on very slowly. These ulcers were caused by a fall which bruised the part but made no wound at the time; two small spots, which she compared to the pustules of small-pox, formed, broke, and gave rise to the ulcers. I applied the lunar caustic to form eschars.
At this time I had not begun to defend the eschar by the gold-beater's skin, and in consequence both these eschars were torn by the patient's stocking having adhered to them, and there was an oozing of fluid from the centre of each eschar on examination on the following day. I again applied the lunar caustic.
On the succeeding day, I found that the large eschar had again been disturbed, the patient having applied a little linen, instead of leaving it exposed. I reapplied the lunar caustic.