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On The Adherent Eschar

Source: Application Of The Lunar Caustic In The Cure Of Certain Wounds And Ulcers

It appears scarcely necessary to describe the immediate and well known
effects of the application of the lunar caustic to the surface of a
wound or ulcer. It may, however, be shortly observed that the contact
of the caustic induces, at first, a white film or eschar which, when
exposed to the air, assumes in a few hours a darker colour, and at a
later period, becomes black; as the eschar undergoes these changes of
colour it gradually becomes harder and resembles a bit of sticking
plaster; in the course of a few days, according to the size and state
of the wound, the eschar becomes corrugated and begins to separate at
its edges, and at length peels off altogether, leaving the surface of
the sore underneath, in a healed state.

In the formation of this eschar several things require particular
attention. The application of the caustic should be made over the
whole surface of the sore; and indeed no part requires so much
attention as the edges; to make a firmer eschar the caustic should
even be applied beyond the edge of the wound, upon the surrounding
skin, for the eschar in drying is apt to contract a little, and in
this manner may leave a space between its edges and that of the
adjacent healthy skin.

At the same time, much attention must be paid to the degree in which
the caustic is applied. In cases of recent wounds unattended by
inflammation, it may be applied freely; but when inflammation has come
on, too severe an application of the caustic induces vesication of the
surrounding skin, and the edges of the eschar may in this manner also
be loosened and removed. If every part is touched, a slight
application of the caustic is generally sufficient.

The importance of avoiding all causes which might detach the edges of
the eschar will be apprehended by the following interesting
observation, which I have been enabled to deduce from very extensive
trials of the caustic; it is, that, in every instance in which the
eschar remains adherent from the first application, the wound or ulcer
over which it is formed, invariably heals.

Not only the cause just mentioned, but every other by which the eschar
might be disturbed, must, therefore, be carefully avoided; and
especially, as the eschar begins to separate from the healed edges of
the sore, it should be carefully removed by a pair of scissors.

To the surface of the wound the eschar supplies a complete protection
and defence, and allows the healing process to go on underneath
uninterruptedly and undisturbed. It renders all applications, such as
plasters, totally unnecessary, as well as the repeated dressings to
which recourse is usually had in such cases; and it at once removes
the soreness necessarily attendant on an ulcerated surface being
exposed to the open air. In many cases too, in which the patients are
usually rendered incapable of following their wonted avocations, this
mode of treatment saves them from an inconvenience, which is, to some,
of no trifling nature.

It has already been stated how important it is that the eschar should
be preserved adherent. To secure this still more effectually, I have
found it of great utility to protect it by a portion of gold-beater's
skin. The skin surrounding the wound is simply moistened with a drop
of water, and the gold-beater's skin is then to be applied over it and
over the eschar, to which it soon adheres firmly, but from which it
may be removed at any time, by again moistening it for a moment with
water; the same bit of gold-beater's skin admits of being again and
again reapplied in the same manner.

The other circumstances which render the eschar unadherent will be
mentioned hereafter. In the mean time the fact stated p. 6, will
sufficiently establish the propriety of treating distinctly of the
adherent eschar.

I now proceed to mention some other effects of the application of the
caustic. The first is that, in cases in which there would be much and
long continued irritability and pain, as in superficial wounds along
the shin, all this suffering, and its consequences in disabling the
patient, are completely avoided. A blush of inflammation forms around
the eschar, but this gradually subsides without any disagreeable
consequences, and the inflammation which would otherwise have been set
up is entirely prevented by the due formation of the eschar.

If inflammation be previously established, it is increased, at first,
by the application of the caustic. But if this inflammation be not
severe, and if the eschar remain adherent, all inflammation, both that
induced by the application of the caustic, and that existing
previously, entirely subsides. When the previous inflammation round
the ulcer is considerable, however, the application of the caustic
would induce vesication, and it should in such a case of course be
avoided, and another mode of treatment to be described hereafter must
be adopted.

I would introduce in this place some observations on the comparative
effects of healing by eschar and by scabbing. On the subject of
scabbing I must refer my reader to the well known work of Mr. John
Hunter. The advantage of healing by eschar over that by scabbing is
quite decided. By comparative trials, I have found that whilst the
scab is irritable and painful, and surrounded by a ring of
inflammation, the adherent eschar is totally free from pain and
inflammation; and that whilst the scab remains attended by
inflammation and unhealed, the eschar is gradually separating, leaving
the surface underneath completely healed. To these observations I may
add that the success of the plan of healing by eschar is infinitely
more certain as well as more speedy than that by scabbing.

I shall, in conclusion, briefly recapitulate the advantages of this
mode of treatment. In the first place, it will be found far more
efficacious and speedy than any other; secondly, it has the great
advantage of saving the patient much suffering and inconvenience; and
thirdly, it renders the repeated application of dressings and
ointments quite unnecessary. Its utility is extremely great,
therefore, where the time of the poor, the expense of an
establishment, and the labours of the medical officer, as well as the
sufferings of the patient, require to be considered; and it will I
imagine be found of no little advantage, in all these respects, in
many cases which are incident to the soldier and sailor.

Next: On The Unadherent Eschar

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