The application of the caustic, of course, produces some pain, but this soon subsides, and the patient experiences more ease than under any other mode of treatment.
Particular cases in which the Caustic is useful.—In punctured wounds, it should be applied to the orifice and surrounding skin, and the eschar allowed to dry. The terrible effects of punctured wounds, are thus completely prevented, whether caused by needles, hooks, bayonets, &c. So also of wounds from saws; of bites from leeches and animals; of the stings of insects; and especially of those small scratches, and punctures, received in anatomical dissections. The danger of these last mentioned accidents may, according to Mr. H., be completely arrested by the prompt and free application of the lunar caustic. Even in neglected cases, when a small tumour has formed under the skin, attended with a smart stinging pain, he advises the tumour to be removed, and an adherent eschar to be formed by the caustic; and in still more neglected and advanced cases, where inflammation of the absorbents has supervened, "a free crucial incision is to be made, the caustic to be freely applied, and afterwards, the cold poultice and lotion; the usual constitutional remedies being actively enforced."
In bruises, especially of the shin, the adherent eschar from lunar caustic, has, with Mr. H., always effected a cure; and even when a slough has been produced, the application of the caustic will moderate the inflammation.
In ulcers, which are small, not exposed to friction or motion, and discharging little, the cure by eschar will be preferable; especially in those little irritable and painful ulcers often seen about the ancle and tendo Achillis. Apply first a cold poultice, and then form the eschar, which may be freely exposed to the air. Should the matter, nevertheless, collect, it should be evacuated by puncture as often as necessary, until the eschar remains adherent.
This practice is recommended by Mr. H., in various other affections; as in inflammation of the fingers; in the fungous ulcer of the navel in infants; in tinea capitis, &c. In this last case, we have ourselves used it with marked advantage. In all cases, the lunar caustic has a decided effect in diminishing the irritability of the parts to which it is applied; and hence should usually be preferred for the purpose of forming a "scab," for such the eschar really is, in a practical view; and we think that our author has hardly done justice to nature's methodus medendi by "scabbing;" while he so ably and strenuously recommends his own imitation of her process. Scabs may be formed by the coagulation of blood; by the drying of mucus or pus; and by the formation of an eschar, by the actual or potential cautery. The surgeon may frequently reduce parts to the same situation, by the use of gold-beater's skin, court-plaster, or other unirritating applications, which prevent exposure and evaporation. In all cases, care must be taken to prevent the surrounding inflammation from transcending the adhesive stage.
45. Hæmorrhage from Lithotomy.—In the London Med. and Phys. Jour. for Jan. Mr. John Shaw has published an account of a patient, who unfortunately perished from hæmorrhage, in consequence of being cut for the stone. The parts being injected after death, it was found, that the bleeding proceeded from the unusual distribution of a branch of the pudic artery, which traversed the neck of the bladder, and lay directly in the way of the incision. The pudic artery was uninjured.
46. Extirpation of the Parotid Gland.—The best surgical writers have condemned this operation, if not as absolutely impracticable, nevertheless, as too dangerous to be ever attempted. Successful cases have however been reported, and Mr. A. Cooper, in a letter to the operator in the following case, avers, that he twice removed the parotid gland in one year. Mr. Kirby, late president of the Royal College of Surgeons in Ireland, in a work published in 1825 at Dublin, on hæmorrhoidal excrescences, has given the details of a diseased parotid, and of the operation for its removal. We condense from Johnson's Review for April, 1826.
The patient was a poor female, aged 40, who had a tumour extending from above the zygoma downwards on the neck, two inches below the angle of the jaw, stretching as far forwards as the anterior edge of the masseter muscle, forcing the ear backwards, and raising it outwards from its natural position. Above the surface, it was about the size of a goose-egg; immoveable; painful when handled; irregular on the surface, and of a deep livid colour over the prominent points. Pains of a lancinating character, extended over the head and neck, producing sickness and want of sleep.
The operation was performed chiefly by the fingers and the handle of the knife, after dividing the integuments by a crucial incision. The branches of the portio dura were of course divided, and great embarrassment arose from a copious hæmorrhage, caused by the bursting of the tumour, while Mr. K. was rooting it out from between the pterygoid muscles. The bleeding was restrained by the finger of an assistant, and the complete extirpation of the diseased gland was effected. Mr. Kirby says, "the space between the pterygoid muscles was void—the auditory tube was fully exposed—the articular capsule of the jaw was brought into view—the finger could trace the length of the styloid process, and on sponging the wound of its blood, it could be seen by those who surrounded the chair." The hæmorrhage was restrained by a sponge firmly lodged at the bottom of the wound, covered by compresses of lint, and the whole secured by a double-headed roller.
The patient was much exhausted, slept tolerably well the next night, complaining of thirst and inability to swallow. On the 2nd day, inflammation, swelling, and fever followed—erysipelas appeared on the neck—patient lethargic—pulse small and frequent. Fourth day, suppuration—symptoms improving—no relapse. The patient completely recovered, without any regeneration of the tumour.