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.