On The Unadherent Eschar

Categories: ON HEALING BY ESCHAR.
Sources: Application Of The Lunar Caustic In The Cure Of Certain Wounds And Ulcers

The eschar is generally adherent in cases of recent injuries, and in

small ulcers, when they are nearly even with the skin and attended by

little inflammation. In other cases the eschar is too apt to be

unadherent, and this arises from the formation of pus or of a scab

underneath.



If the eschar be unadherent by subjacent pus, it may be ascertained in

the space of from twelve to twenty-four hours; the cent e is generally

observed to be raised and to yield to the pressure of a probe;

sometimes the subjacent fluid has partly escaped by an opening at the

side of the eschar.



When a scab forms underneath the eschar, which does not happen except

the fluid has been allowed to remain too long under the eschar without

being evacuated, there are pain and some inflammation, the eschar does

not separate, but remains long over the sore, and there is no

appearance of healing.



When it is ascertained that there is fluid underneath the eschar, a

slight puncture is to be made by the point of a penknife, the fluid is

to be gently pressed out, and the caustic is then to be applied to

the orifice thus made. The same plan is to be adopted if the fluid

ooze out at the edge of the eschar; it is to be fully evacuated by

pressure, and the orifice is to be touched with the caustic. The

healing process goes on best however when the orifice is in the centre

of the eschar. After this treatment the eschar occasionally remains

adherent, but more frequently the fluid requires to be evacuated

repeatedly, and this should be done every twelve hours, or once a day,

according to the quantity of fluid formed, taking care that the eschar

be not needlessly separated by allowing the fluid to accumulate

underneath. If, from accident, the eschar is separated before the sore

be healed I would reapply the caustic. At length the eschar becomes

adherent, and in due time begins to peel off, leaving the surface

healed.



In every case in which the eschar does not separate favourably, I

begin to suspect the formation of a scab underneath, in which case the

whole must be removed by the application of a cold poultice for two or

three days; this has not only the effect of removing the eschar but of

allaying any inflammation or irritation; afterwards the caustic must

be reapplied as before.



The gold-beater's skin is more useful as a protection to the

unadherent than to the adherent eschar, as the former would be more

liable to be torn off by accident than the latter. The gold-beater's

skin must be removed in the manner already described, whenever the

subjacent fluid is to be evacuated, and must be reapplied after

touching the orifice with caustic.



The pain experienced on the application of the caustic is greater or

less according to the sensibility and size of the wound. In small

wounds it is trifling, and of short duration; it is more severe in

recent wounds than in ulcers; it soon subsides in every case, and

then the patient enjoys greater ease than would be experienced under

any other mode of treatment. Little or no pain is caused on applying

the caustic after evacuating the subjacent fluid of an unadherent

eschar. Altogether the pain inflicted by the caustic is far less than

is generally imagined, and forms scarcely an obstacle to its

employment.



It may be proper, in this place, to notice such circumstances as

render the employment of the caustic improper or inefficient. It is

improper to employ the caustic when the ulcer is too large to admit of

the formation of a complete eschar; or when it is so situated as to

render it impossible that the eschar should remain undisturbed, as

between the toes, unless, indeed, the patient be confined to his

bed;--or in cases attended by much inflammation, or by much oedema.



I have found no kind of caustic so manageable as the lunar caustic;

and this is best applied in the solid form. I have thought too, that

the newly prepared lunar caustic is more apt to dissolve on being

applied than that which has been longer made and more exposed to the

air; the latter is therefore to be preferred.