OBSERVATIONS UPON THE NATURE AND TREATMENT OF BOIL AND CARBUNCLE.

happened to be asleep when I entered the ward, and the nurse object we should steadily keep in view is, to allow the iris to abruptly woke her. Startled, she jumped up hastily, and im- recover its position, and the section to become firm. The utter mediately complained of her eye, which seemed (she said) vio- inability to raise the lid points out that Nature requires it to lently squeezed, and pulled back in her head. The occurrence remain closed, in order that she may perform her work. vexed me, knowing the probability of the section being disIt is generally recommended that the prolapse should be .turbed ; but I directed that the

eye should be well and

care-

fully fomented, prescribed a sedative draught, and desired the patient to keep perfectly quiet. Nevertheless, the lid began to swell, with a sensation as if a pea were under it-unmistakable indication of prolapse. On the seventh day I examined the eye, and found large protrusion of the iris, and considerable inflammation. Six leeches were applied with marked relief, and frequent fomentation ordered, and in the course of a few days the redness subsided. The eye was kept almost constantly closed for a month, and the prolapse was twice touched with nitrate of silver; some irritation followed the second application and it was not repeated. Belladonna was used, and gentle .pressure by means of a soft compress and bandage was applied with some advantage, but notwithstanding all my efforts, the iris did not retreat sufficiently to admit of the pupil recovering itself, and useful vision was for a time suspended. I say suspended, because in this case there was not sufficient inflammation to permanently injure the eye, and the closure of the pupil was the only obstruction to sight. Here an artificial pupil can be made with great facility, and there is little doubt of vision

being restored.

The symptoms then, gentlemen, of spasms of the muscles of the eye are, sudden acute grasping pain, with a sensation as if the eye were drawn back in the socket, generally attended with coruscations of light and colours, the result of compression of the retina. In the majority of cases it comes on within the first thirty-six hours after operation, generally during the brief interval between sleeping and waking, or just when the patient is dropping off to sleep, and is most marked in persons who have suffered from disturbance of the nervous system, as indicated by neuralgia, spasms, and cramps. , The immediate indication is to tranquillize the nervous sysand this object is best attained by a soothing cordial draught, composed of thirty drops of Hoffman’s anodyne, twenty drops of Squire’s solution of bimeconate of morphia, and a drachm of the compound tincture of lavender, in an ounce of water. In some cases I have given six or eight drops of the tincture of Cannabis Indica on a lump of sugar with excellent effect. The most grateful application to the eye itself is a fomentation of hot water, but in using this the utmost gentleness is necessary, the irritability of the eye being so great that a very slight touch will often bring on a return of the spasm. For the same reason, it is preferable to darken the room, thoexcluding the light from the patient, rather than to roughly irritate the eye by compressing it with bandages. And here let me give you a hint: never allowa looking-glass to remain in the patient’s room. I have several times known much annoyance caused by a gleam of light falling on a mirror, and reflected to the face ; for the same reason have any ’, chinks in the shutters stopped up ; more mischief may be done z’i by a bright ray of light streaming through a crevice, than by a considerable amount of general light, gradually admitted. It must be borne in mind that, for the better illustration of my subject, I have selected the most marked cases in my note-book. It by no means necessarily follows that destruction of the eye should follow spasm of the muscles ; the immediate effect will almost certainly be disturbance of the section and prolapse of the iris. The prolapse may, however, subside, or not be sufficiently great to interfere materially with the success of the operation ; or again, if the prolapse be so considerable as to cause obliteration of the pupil, vision may still be restored by an artificial pupil. Prolapse of the iris will be indicated by a slight oedematous swelling, commencing at the inner canthus, and stealing along the margin of the upper lid ; the lid becomes exquisitely tender, so that the patient shrinks from the slightest touch, and there is generally the sensation of a foreign body under it. There is a copious discharge of scalding tears, the patient avoids light and the slightest movement of the lid. If you do manage to raise the lid, you will find the cornea thrown upwards, and there will be more or less redness of the conjunctiva and sclerotic ; simultaneously with these local indications the patient will complain of aching over the brow, extending down the side of the nose and cheek-bone, which is tender to the touch ; the pain is aggravated at night. The treatment which I believe to be best for prolapse of the iris is, first and above all, absolute quiet of the eye ; the least handling or attempt to open the lids almost certainly brings on a return of the spasm, and of course keeps up the mischief. The

tem,

some cases I have seen this the whole, I am of opinion that time and quiet will attain the great object better and with less hazard than the use ofthe caustic. I remember a case in which I assistecl the late Mr. Dalrymple. Three weeks after extraction the eye remained irritable, there being a small prolapse, but sight was returning favourably. Wishing to hasten matters, Mr. Dalrymple touched the prolapse with caustic : violent pain came on, subacute inflammation followed, and the eye was lost. I believe that he used caustic no more in such cases. Time ’and quiet, then, are the main agents in the cure of prolapse of the iris; when the cicatrix is forming, advantage may be derived from the use of belladonna; and if there be congestion, the application of a leech or two from time to time will be serviceable. There is one thing, however, which we are called upon to ameliorate, and that is the frontal neuralgia. An ointment, composed of one drachm of extract of opium to four drachms of strong mercurial ointment, well rubbed in at night, is often efficacious; but I have found still greater relief afforded by painting the painful surface freely with a lotion composed of one grain of nitrate of silver dissolved in half an ounce of nitric ether. This sometimes acts like a charm in removing the pain. Another useful application is chloroform thus applied: a layer of cotton-wool is to be spread over the forehead, then sprinkled with chloroform, and covered with oiled silk. The vapour is thus confined without coming in contact with the skin. There is a point in the after-treatment of cataract cases to which I would draw your attention-namely, the importance of avoiding any sudden startling of the patient, especially from sleep; as I look back upon the cases in my practice in which there has been prolapse of the iris, I may ascribe this mainly to two causes-the eye being struck, or the patient being startled. It is not necessary that there should be a real blow; a mere touch will be sufficient to cause a sharp action of the muscles of the lids and of the eye, and so the flap may be displaced. When, therefore, the eye is being cleansed, tho patient should always be warned when the sponge or rag is going to be applied; for if not so prepared, a start will generally take place, and the eye may be struck. I have described in case 2 the consequences of an alarm caused by the clumsiness of a servant. Impress upon the attendants the importance of quiet, and the most rigid attention to your instructions. These must be laid down with precision, especially when you have not the assistance of a nurse experienced in the management of eye cases.

touched with nitrate of silver.

useful, in others hurtful; and

patient’s

(I

574

In

on

OBSERVATIONS UPON THE

NATURE AND TREATMENT OF BOIL AND BY

CARBUNCLE. BENJAMIN TRAVERS, JUN., ESQ., F.R.C.S.L, &c.,

FORMERLY

RESIDENT

ASSISTANT-SURGEON AT ST. LECTURER ON SURGERY.

THOMAS’S HOSPITAL,

AND

PART II. OF INCISION.

IT is probable that this has been the rule of practice hitherto, both at home and abroad, although, from time to time, some must have had their misgivings, in the face of several accidents, which commonly follow an unsparing use of the knife. In the middle of the last century, Pouteau published a case in which the side of the face was burned deeply with a hot iron for the purpose of discharging a collection of this kind. The patient, a woman, recovered perfectly. It is not to be wondered at that so formidable a remedy never became the fashion. Dionis declares that there is nothing for it but cutting deeply, with the air of a person who would have preferred a milder method. English surgeons appear uniformly to have recommended this mode of operating, which, it must be confessed, is still the prevailing fashion, in spite of profuse haemorrhage, a wound which at best heals slowly, and a ghastly scar. I am not willing to assert dogmatically that it is always inexpedient

to

employ the knife,

but the occasion will present itself but

rarely to anyone who has once witnessed the effects of a strong caustic in procuring all that is obtained by cutting, upon far easier and safer terms. It may happen in a carbuncular inflammation that the first stage, or that of tension, is much prolonged and very painful, without much discoloration of the skin. Here great present relief may sometimes be obtained by passing a straight knife through the skin and superior part of the swelling. In the young plethoric habit I have known this done with impunity, nay with advantage; and whether the opening so made be rectilinear or crucial, it is a practice strictly consistent with the use of the caustic potash at a later time, which may be applied to the wound with good success on the second or third day, or whenever the slough is visibly progressive and on the increase in the part. A plaster may occasionally be applied before the occurrence of ichor and pinhole opening. After all, there is no novelty in this suggestion; it is a common method of treating boils amongst the vulgar, before they have arrived at maturity. The notion which I am especially desirous of seeing exploded is, that deep cutting can finder any circumstances become either requisite or safe. An incision to include the base of the swelling must in carbuncles be very extensive. It is not denied that it is impossible to calculate the amount of blood which may be lost in cutting a large anthrax upon the nape of the neck. Many old people have never rallied after such an operation. They do not die immediately, but the local process of dissolution thus acquires an impetus which they are wholly unable to resist. The work èf elimination proceeds slowly or remains wholly suspended, and the appetite fails; full opiates cease to produce refreshing sleep; the patient becomes drowsy and more feeble; the temperature of the body is not maintained equably; the pulse is subject to intermission or begins to jerk; hiccough supervenes; respiration is performed with difficulty; and sooner or later the patient dies, retaining his intellectual faculties to the last. a sudden and irreparable declension of the powers of the system is due solely to excessive haemorrhage. It is neither affirmed nor pretended that many have not survived the use of

Such

the knife, even in advanced life; but such recovery is endangered by the loss of blood to an extent which is without excuse, inasmuch as it is wholly unnecessary. Another bad conse-

quence of deep or early cutting is, the slower separation of the and the little control which it exerts over a spreading induration. A patient so treated is not uncommonly obliged to submit to repeated dilatations, he being now in a state of his former sufferings prostration which profoundly aggravates C,9 and present danger. There is nothing of which Nature is more impatient than any interruption to the course and final purpose of the adhesive process. Frequent cutting interferes with that barrier, production of lymph, which waits upon all local inflammation not terminating in a present resolution. Hence suppuration and sinus; and having retrograded to that extent, it may be said that the work of repair must commence afresh, Lastly, the period of cicatrization is materially influenced by the use of the knife. I have seen the entire cheek seamed as it would be by a deep sabre cut, and the patient frightfully and permanently disfigured by his inability to close the eyelids, after repeated incision of the cheek secundum artem. I subsequently applied the potassa to the same side of this gentleman’s face. The result was a large eschar in front of the angle of the j’aw. After the lapse of two years scarcely a trace remains of the site of a dense slough of the size of a sixpenny-piece. It may be confidently asserted, that the risk of deformity is very slight after the use of a quick caustic. It provides for the formation of a sore far more disposed to early contraction and a smooth cicatrix, than the irritable margin of a deep incision.

- sloughs

-

PART III ON ON THE THE USE USE OF OF THE THE POTASSA j.. FUSA. USA.

Ix certain cases of cancer, and other anomalous sores, it is probable that our faith in the local efficacy of strung caustics is Undergoing a revival. The operation of the pure kali in ehanging the face of a smooth and excavated ulcer, discharging a thin ichor, into a healing surface, is very marked. I have known such an action to be arrested by this means, where there appeared to be no alternative to the performance of a complete excision of the part. I am now about to exhibit the decided advantage to be thus obtained in the treatment of boil and carbuncle. By the use of the pure kali, a large anthrax may be destroyed and eliminated with a rapidity and an absence of suffering wholly without precedent in cases where recourse has been had to the scalpel.

In the language of Dr. Physics, "there are three stages in this disorder. The first is premonitory. In the the skin has become dusky, and is perforated by pin-hole orifices, At this time our inwhence there is an ichorous oozing," &c. terference is an urgent necessity. The effect of a caustic is now most marked, and a succession of very severe cases during the past three years has convinced me of the truth of this statement. The formation of a large eschar being a close imitation of Nature’s method of opening the skin, and which she desires to effect without loss of blood, cannot be wrong, and, indeed, experience proves that it is a safe and judicious proceeding. The pure potassa having a bluish tint when first cast, which it derives from the iron mould into which it is run, is probably the most valuable caustic which we possess for general purposes. It is quite manageable with a little care; it does its work rapidly, if only pure and dry. It kills outright all moist animal substances with which it comes into contact. It gives a good deal of pain sometimes for the first ten minutes after its application, and sometimes the patient makes little or no complaint. If there is nothing more than uneasiness after the operation, it is a sign either that the preparation has lost its virtue, being converted into a carbonate by prolonged exposure to the vapour of the atmosphere, or it may have been inefficiently applied, or at a wrong time, and before there is any sufficient indication of the points at which the skin will first give way. Lastly, the powers of life may be so sunk that the insensibility of a protracted exhaustion is made manifest by an entire exemption from all suffering of an acute or prolonged character. - The caustic-stick may be inserted into a goose-quill by way of handle, in which state it should be preserved in a closelystoppered phial, or it may, when wanted, be simply picked up with a pair of forceps. The operator then twists some stout paper about one end of the material, and it is ready for use. In the case of a moist or discharging surface, there is no occasion to employ any water. The solution of the caustic is sufficiently provided for by the condition of the parts concerned. When first I used this material in the treatment of boils and carbuncles, I found that the fluid slough sometimes overran the margin of the wound or eschar, and a serious excoriation followed wherever this stream had passed along the cuticle. To avoid this, a dossil of dry flocky lint should be applied upon and around the new opening, and this may be allowed to remain there for some hours with advantage. It is absorbent, and defends the wound from extraneous irritation of all kinds. When a frothy, yeast-like action is seen to commence, and the parts become very dark, it is right to desist; in other words, the effect has been produced. The patient is now directed to preserve the attitude of repose, or, at all events, to remain quietly in his chamber. if the pain be prolonged, or the subject weakly, cordials, or even a full opiate, may be given with advantage. The application having done its work, and the chemical action having ceased, the pain soon subsides, unless the anthrax be unusually deep and extensive. In this particular I can, from numerous observations, fullv confirm the experience of Dr. Physick; in short, this and the early separation of the sloughs, constitute two of the strongest arguments for substituting the use of the caustic kali for the knife. Some after-pain there always will be, and that, for a few minutes, may be severe. The patient might express a wish to inhale an anaesthetic. I am not sure that this practice would be always unattended with risk in very large carbuncles in old people, when situated upon the nape of the occurring neck, or in the occipital region; but, in numberless other instances, I am not aware of any reason why an anaesthetic should be withheld, though few probably would deem it worth while to wait for such aid, were the operator not so provided at the moment. It is unnecessary here to say more of the third stage—wherein the sloughs are cast off and granulations that these processes have acquired make their a progressive activity in the course of a week. A large granalatingchasm upon the nape, in which I could easily place the back of my four fingers, has been more than once established after using the potassa, in the course of one week from the time of applying it, where, after using the knife, no similar condition has been achieved at the end of three or four. Of course there is uneasiness, and the appetite must be coaxed, and sleep secured by a full opiate every night if necessary. The carrot-poultice is the best that can be employed with a view to early cleaning and incarniug the sore. I may here also take occasion to recommend the yellow basilicon ointment, also a solution of the chlorinated soda, as being very good apto this c1aRS of sore at particular stages or nerinds of plications * Vide Pmiadetohta. Jour, al.of M cal aRJ. lUMiCal ;:)Cre.tl,6, V(14. n.

second,

appearance-than

575

the healing process. Of the constitutianal treatment of boils tions were reports of three cases of diabetes, in which the and carbuncles, I shall have more to say in another place. In rennet, or liquor pepticus prseparatus, as it may be called, apsome bad cases, I have obtained a good result-nay, I have peared to have acted in a highly satisfactory manner, and to twice been singularly successful in the use of the caustic, where the contents of that paper I beg to refer the reader once more. the parties had previously submitted to the old rule of prac- Since then three more cases have come under my treatment, tice-viz., incisions, with the worst possible consequences; but the results of which I will now lay before the profession, as it is expedient for me to state, in conclusion, that matters are additional and conclusive evidence upon the subject. But beonly aggravated by applying a feeble irritant like the nitrate fore doing so I will offer a few remarks upon the principle of silver instead of a quick consuming substance, such as the upon which the remedy is used, and which again suggests, as pure kali, however well-timed or advisable the operation may was observed by me at the conclusion of the former paper, a be in other particulars. Some years ago, before I was conver- far more extended application of the medicine than merely as sort of specific in diabetes, which it is not; for nothing can sant with the nature and advantage of the plan of treatment advocated in this paper, a gentleman showed me what is called be viewed as a true specific, except that which acts by dean angry boil on the side of his neck. The skin was very red stroying the entity of the cause of disease, as mercury in rela. and hard in its neighbourhood, and its apex was prominent, tion to the syphilitic virus, muriatic acid to putrid matters,, being occupied by a large bead of pus. I ruptured the pustule, alkalies to acids, &c. &c.; whereas the rennet or liquor peptiand then applied the nitrate of silver to the collection with cus is simply a substitute for what is wanting in the body, considerable freedom. being analogous to, or identical with, the constituents of the In the course of twelve hours, violent pain ensued, the sur- frame itself, within which it takes up its position, and perrounding skin became tense and red, indeed, almost livid, with forms its functions just as aptly as if it had been secreted greatly increased swelling of the surrounding tegument : in within such body, and so had formed a natural portion of its short, the tumour had now acquired the dimensions of a car- scheme-work of organization. as a buncle. In deference to a second opinion, this tumour was Now, the practical application of this great deeply incised, and many weeks elapsed before the patient was matter of instinct, has been coeval with time itself, as evifinally restored. Much blood was lost by the second operation, denced in the use of animal flesh, the desire for water as a an accident which, if it did not endanger the patient’s life, at beverage, and the universal demand for salt, lime, sulphur,. all events very much retarded the approach of convalescence. phosphorus, &c. &c., or their analogues, as represented in Postscript. -The impression that the use of the caustic potass special kinds of food, such as garlic, onion, spices, fruits, and is a far safer and more scientific mode of procedure in the treat- so on, each containing particular ingredients that are essential ment of large and devastating carbuncle than the ordinary plan" to the constitution of healthy blood, and of the other tluid and of treatment by incision. will speedily pass into strong con- solid parts of the body. But the scientific recognition of the viction with such as are willing to be guided by the patent evi- principle is of a date comparatively recent, and has only been dence of fact rather than the blind guidance of hearsay teach- the natural sequence of a more intimate knowledge of the eleing or the poor rules of custom and connivance. The rapidity mentary constituents of the living system, and of their relation with which enormous sloughs are cast off ; the elasticity shown to each other while within such system, as well as of the uses of the various complex fluids which are therein created, as it even in old and broken habits, at a time when the constitutional powers commonly give way irretrievably under the were, out of the primitive elements furnished originally from older method ; the activity of the granulating and contracting the soil or from the air. Thus, under such advanced knowperiod, are so marked, and have received such repeated connr- ledge in organic chemistry, has iron come to be rationcally emmation within the limited range of my own personal observa- ployed in cases of anaemia, gelatinoid phosphate of zinc in tion, that I cannot but reiterate, as a matter of certainty, that rickets, and various other diseases arising from mal-nutrition, the artificial destruction of so much skin and subjacent tissue cod-liver oil in deficiency of the fatty elements, ox-gall in toras must, under any circumstances, die and be got rid of by the pidity of the liver, albumen in albuminuria, and even prepared sloughing process, should always be provided for by this blood itself in certain cases of defectiveassimilation, as affordmethod. which is so close an imitation of the work of the ing to the stomach, like eggs and milk, all the various elements of nutrition nearly in the exact proportion in which they are One apology for incision I am wholly at a loss to appreciate, wanted. We must recollect, however, that without a due It is stated that early cutting saves supply of the healthy gastric juice, even such diets as those as I cannot understand it. the structure of the common integument. The discoloured, last mentioned could never be resolved into proper pabulum fit boggy, ulcerated skin tissue must always die to a limited ex- for the sustenance of the frame; and hence the obvious and tent. If it be incised, it encounters no fresh provocative to direct utility of the rennet, or prepared liquor pepticus, in all early separation : its de-vitalization is already so complete, cases where the digestive power languishes, as furnishing to a that all idea of sudden relief, such as might be entertained in body incapable of duly producing it, that which is prepared the face of a simple congestion, must be abandoned. The use within another body in a healthy condition. It is true that of a cutting instrument exerts no influence for good, either pre- we already possess various remedies that may excite the to increased activity, and gentian, colomba, sent or prospective, in parts so circumstanced. Incision is but stomach, &c., a superadded irritation, which commonly induces further indubibsrine, and all the other stomachics or appetizers, may sucration, and at a later time obstinate sinus and renewed slough- ceed in our hands under certain circumstances; but in others’ will not. They all act in an indirect manner as ing. Thus much for the varied local results of these two very again they tonics or stimulants, and their defects will much dea risk of and The remedies. gastric opposite haemorrhage, present sudden diminution of all the vital powers, constitute, after all, pend upon whether the disorder be merely functional or organic. the prime objection to the scalpel, as it enforces the necessity In the former case they will be efficacious ; but in the latter for having recourse to a far more lenient and philosophical scarcely or not at all, and perhaps even injurious. Not so with method, so happily suggested by the existence of a remedy, this gastric liquor, for the utility of its employment is as clear and direct as that of water itself to the thirsty animal or driedwhich on such occasions I do not hesitate to term invaluable. up plant; and though it has not hitherto been regularly used for its medicinal ends, such accident is only illustrative of the old familiar fact, that plenty of knowledge may exist without ON being practically applied; just as the world knew of the exof steam, and of the rapid transmission of the MELLITIC DIABETES, IN REFERENCE TO pansive powers electric fluid long before steam engines or electric telegraphs ITS TREATMENT BY RENNET, OR LIQUOR were devised. Empirically it certainly has been employed under the shape of whey-drinks, these having been considered PEPTICUS, PRÆP. remedial in cases of rickets, tabes, pulmonary consumption, BY DAVID NELSON, M.D. EDIN., and all the other varied forms of tuberculosis, or general granular degeneration. It has thus been exhibited just as burned LATE PHYSICIAN TO THE QUEEN’S HOSPITAL, AND PROFESSOR OF CLINICAL MEDICINE IN QUEEN’S COLLEGE, BIRMINGHAM. sponge was wont to be used for glandular accumulations, without any just apprehension of the essence upon which its efficacy IN a former paper upon this subject, which appeared in depended. And even though Reaumur and Spallanzani, so as about eighty years ago, clearly did demonstrate to the THE LANCET of the 20th of January, 1855, I quoted cer- long satisfaction of themselves and others, that the gastric juice, tain general observations from a Clinical Lecture delivered by after being extracted from the body, could dissolve ments even myself several years before, and published in the Provincialz in glass vessels, provided they were kept at a blood heat, yet, Medical and Surqical-Jou1’Iwl. Appended to these observa- being more devoted as physiologists than physicians, they did

a

principle,

naturalsurgeon.

a,

576