An essay on the use of the nitrate of silver : in the cure of inflammation, wounds and ulcers

Front matter

XTbe (Sift of

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ON THE USE OF THE NITRATE OF SILVER.

Introduction

ON THE USE OF THE NITRATE OF SILVER

IN NAVY, ARMY, HOSPITAL, AND

DOMESTIC SURGERY.

I think it important, in a few introductory observations, to draw the attention of surgeons to the obvious utility of the remedy which is the subject of the following pages, in the several departments of army, navy, and hospital practice.

The nitrate of silver is so portable, and renders the multiplicity of dressings usually applied in many surgical cases so unnecessary, that it must be of great advantage in circumstances in which it is of importance to be as little incumbered as possible by baggage.

The application of this remedy is, in general, too, so simple, and its operation so prompt, that the periods of residence in hospitals may, by this means, be, in many cases, very greatly shortened.

Vlll INTRODUCTION.

Another advantage of the nitrate of silver is, that, instead of the daily dressings required in many wounds and ulcers, an attention to the patient every third or fourth day is frequently all that is required. These advantages are very great in all hospitals, but particularly so in regard to the class of out-patients, the number of which is increased, whilst that of in-patients is proportionately lessened, by the practicability of curing many cases, by means of the nitrate of silver, without rest, which would otherwise require long confinement upon a bed or couch.

In the army and navy surgical departments, the nitrate of silver will be found of the utmost advantage by its obvious efficacy in preventing inflammation in contused and punctured, and especially in bayonet and gun-shot wounds, and in inducing the adhesive inflammation in incised or sabre wounds. Three cases of gun-shot wounds, treated by the nitrate of silver, are given in the Appendix.

In hospital practice, most of the patients with ulcers of the leg, hitherto made in-patients,

INTRODUCTION. IX

may, I am persuaded, be treated as out-patients ; and thus the funds and means of these establishments will indeed be greatly economized, and their advantages extended to patients who must otherwise have been excluded.

The nitrate of silver will also, I am persuaded, one day constitute an important article in what may be termed domestic surgery.

In collieries, in factories, and in other situations in which the persons employed are liable to contusions, and similar accidents, a ready remedy possessing the power of preventing inflammation and sloughing, must prove an invaluable acquisition.

I would, in this place, correct a prevailing error in regard to the action of the nitrate of silver. It has been termed a caustic. This is altogether erroneous. It is the very reverse of a caustic. It is impossible to destroy any but the most superficial parts by the nitrate of silver. In this it differs widely from some other substances to which the same term has been applied.

X INTRODUCTION.

I speak of it in its solid form. Instead of destroying, it frequently preserves, parts which would inevitably slough except for the extraordinary preservative powers of this remedy.

A new term is, in fact, required for the peculiar kind of influence which the nitrate of silver possesses, in subduing and checking inflammation in phlegmon and erysipelas, — in inducing the adhesive inflammation in wounds, — in preserving the health of parts which, in cases of puncture or bruise, are ready to take on the suppurative or sloughing process, and, lastly, in changing various specific actions and inducing one of a more healthy and curative kind.

Is it not, indeed, by subduing inflammation and irritation, that the nitrate of silver relieves stricture of the urethra ? And may not this fact suggest the application of this remedy in other similar affections of internal canals ?

This suggestion is much confirmed by the case of contracted rectum, successfully treated by the nitrate of silver, given in the Appendix.

INTRODUCTION. xi

May not the nitrate of silver be employed, to exclude the atmospheric air, to close the external wound, and so to reduce the dangerous circumstances of a compound fracture to that comparative simple and innocuous case of a simple fracture ?

May not this remedy become useful by its power of subduing inflammatory action, or as a prompt mode of blistering, in phrenitic, pleuritic, peritonitic, and other internal inflammations ?

But the questions in regard to the obvious further advantages of this remedy, are innumerable. By what has been done already, it may, I think, be conjectured how much may yet be effected by a steady and persevering investigation. Each day supplies fresh incentives to exertion, and to renewed trials of the curative powers of this remedy, and I trust that much will still be discovered in regard to the utility and efficacy of the nitrate of silver.

It is but just to add, that this should rather be regarded as a new work upon the same

Xll INTRODUCTION.

subject, than as a second edition of my former little volume. My subsequent investigation of the effects of nitrate of silver, has indeed been so satisfactory that the greater part of the following pages are occupied by subjects scarcely touched upon in the first edition ; I had but conjectured, at that time, that phlegmon, erysipelas, inveterate ulcers, &c. as well as punctured and bruised wounds, would find so easy and effectual remedy in the nitrate of silver.

There are still affections in which the nitrate of silver should be tried. One of these is inflammation of the vein. I cannot but hope that it will prove a remedy in many cases of this formidable disease.

One final remark I would add in this place. I have never known the nitrate of silver to do the least real harm. It may have induced vesication, when the skin has been tender ; but this has been so trifling an affair as scarcely to deserve notice.

Contents

INTRODUCTION.

TAGE.

ON THE USE OF THE NITRATE OF SILVER IN NAVY, ARMY, HOSPITAL, AND DOMESTIC

SURGERY vii

Chapter I. Of The Principles Of The Treatment By The Nitrate Of Silver

I. Of the Nitrate of Silver, as a remedy in external

inflammation 1

II. Of the Nitrate of Silver, as a means of inducing

the healing process, or adhesive inflammation. 6 III. Of the Nitrate of Silver, as a means of healing

by Eschar, . . 9

1 . Of the Adherent Eschar ib.

2. Of the Unadherent Eschar 15

3. Of the Eschar and Poultice 18

Chapter II

OF THE USE OF THE NITRATE OF SILVER IN THE TREATMENT OF EXTERNAL INFLAMMATIONS.

I. Of Phlegmonous Inflammation 20

II. Of Whitlow 26

III. Of Erysipelas 28

IV. Of Inflammation of the Absorbents 48

XIV CONTENTS.

Chapter III. Page

OF THE TREATMENT OF PUNCTURED WOUNDS. 58

I. Of Simple Punctured Wounds 62

II. Of Punctured Wounds with Inflammation 67

III. Of Neglected Punctured Wounds 70

IV. Of Large Punctured Wounds 80

V. Of Wounds received in Dissection 81

VI. Of the Bites of Animals 85

VII. Of Inflamed Leech-bites 89

Chapter IV. Of The Treatment Of Bruised Wounds... 92

I. Simple Bruised Wounds 95

II. Inflamed Bruised Wounds . « 102

III. Bruised Wounds with Slough 106

IV. Severe Bruised Wounds 107

Chapter V. Of The Treatment Of Ulcers 112

I. On Healing Small Ulcers by the Unadherent

Eschar .. 114

II. Of the Cure of Ulcers with Inflammation 118

Chapter VI. On Old Ulcers Of The Legs 128

Cases of Old Ulcers in the Legs. 134

CONTENTS. XV CHAPTER VII.

PAGB

OF BURNS AND SCALDS 149

I. Cases of Recent Burn 151

II. Erysipelas from a Burn 153

III. Hard and painful Cicatrix after Burn 157

APPENDIX I.

I. Of the use of the Nitrate of Silver as a Blister. 161

1 . Case of Blistering by the Nitrate of Silver

in Enlargement of the Knee 162

2. Case of Blistering by the Nitrate of Silver

in Inflammation of the Urethra, 163

II. Cases of Gun-shot Wounds 166

III. Cases of Neuralgic Affection 170

IV. Case of Contracted Rectum 172

V. Case of Ulceration of the Tongue 174

VI. Case of Irritable Ulceration near the Eye .... 175

VII. On the Fungous Ulcer of the Navel in Infants.. 176

VIII. On the Treatment of Corns 177

APPENDIX II.

I. Letter from Mr. Webster, Surgeon, Dulwich 179 II. Letter from Mr. Tobias Browne, Surgeon,

Cambenvell 200

OF THE USE OF THE NITRATE OF SILVER,

I. Of the Nitrate of Silver, as a remedy in external inflammation.

I am not aware that the influence of the nitrate of silver, in subduing inflammatory action, has been at all noticed by surgical writers ; much less have its unexpected and extraordinary powers in this respect been fully ascertained.

That the application of the nitrate of silver

ERRATUM.

Page 56, line 4, for presented, read prevented.

OF THE USE OF THE NITRATE OF SILVER,

Chapter I. Of The Principles Of The Treatment By The Nitrate Of Silver

I. Of the Nitrate of Silver, as a remedy in external inflammation.

I am not aware that the influence of the nitrate of silver, in subduing inflammatory action, has been at all noticed by surgical writers ; much less have its unexpected and extraordinary powers in this respect been fully ascertained.

That the application of the nitrate of silver should subdue the inflammation of phlegmon or of a line of inflamed absorbents, arrest the spreading of erysipelas, prevent and modify the formation of pus, are facts, I believe, totally new. I am thus distinct in my statements of the effects of the nitrate of silver, which I am about to describe as the results of my own investigation, because I cannot by any means be supposed to claim or to have suggested all the beneficial applications of this useful remedy.

In some cases of external inflammation it is sufficient merely to blacken the cuticle. How this apparently simple process acts in subduing the inflammatory action, I am quite at a loss to determine. But it is my object simply to ascertain and state practical facts. It is plain, however, that a chemical union takes place between the metallic salt and the animal substance, by which its pores are obliterated and the action of the external air excluded.

In other cases it is necessary to induce a degree of vesication. This kind of vesication is less irritable than that induced by cantharides, and it has a singular and peculiar effect in subduing the process of inflammation.

In some instances the application of the nitrate of silver has appeared to prevent suppuration. In others, a fluid obviously felt fluctuating before, has been absorbed. And in others, the pus which would otherwise have been viscid and opaque, as contrasted with that of similar affections in the same case in which the nitrate of silver had not been applied, is rendered thin and limpid, and perhaps streaked with blood, pierces through a smaller orifice, and leaves the abcess in a state more disposed to heal.

It is evident from these observations, that the influence of this remedy is not confined to the textures constituting the skin, but that it extends more deeply, exerting itself upon the condition of the cellular substance, and even of parts more deeply seated still.

I must be excused for observing, that I consider all these facts, in regard to the effects of the nitrate of silver, applied externally, to be new, whatever was known of its use before. They will be amply established by the cases

b 2 reserved for the subsequent parts of this essay.

It is still a question how far the application of the nitrate of silver may be useful in internal inflammations, by inducing prompt vesication over the inflamed part, or even without inducing vesication.

I now proceed to state more particularly the different modes of applying the nitrate of silver, with the view of subduing external inflammation.

It is frequently only necessary to convert the cuticle into an eschar over the inflamed surface. In other cases, the nitrate of silver must be applied more abundantly, so as to induce vesication ; the part is first to be washed with soap and water, to remove any oily substance from the skin, and then it is to be wiped dry ; the inflamed and surrounding skin then to be moistened, and a long stick of nitrate of silver is to be passed over . the moistened surface, taking care that not only every part of the inflamed skin be touched, but the surrounding healthy skin, to the extent of an inch or more bevond it, in severe cases,

The nitrate of silver may be then passed over these surfaces, once, twice, thrice, or more times, according to the degree of inflammation ; once in slight cases, twice or thrice in common cases, and more frequently if quick vesication be required. It is necessary to apply the nitrate of silver more freely on the hand or the sole of the foot, where the cuticle is thick, than on other parts. After the application, the part is to be exposed to the air to dry, and is to be kept cool.

In twenty-four hours, if the nitrate of silver has been properly applied, it will be frequently observed that the inflammation has subsided, and its progress been checked ; but if there be any inflamed spot left untouched, the patient will complain of it. To every such spot the nitrate of silver must be applied. At this period there is usually a little vesication.

On the third day there is usually more vesication and less swelling, and the patient complains of a little pain, as of that of a blister ; but, on pressure, the part has a punyfeeling, and is found to be quite free from inflammation.

On the fourth day the vesications begin to disappear. It is best to leave them undisturbed ; for the dried exudation defends the subjacent cutis.

On the fifth day the vesicated crusts separate, leaving the subjacent parts free from soreness and inflammation. It is sometimes a number of days before the whole of these crusts peel off; but I believe it is best to leave them undisturbed.

II. Of the Nitrate of Silver, as a means of inducing the healing process or adhesive inflammation.

I have already mentioned that abscesses over which the nitrate of silver has been applied, are left in a state more disposed to heal, than similar abscesses, in the very same case, in which this remedy had not been used. It would therefore appear that the nitrate of silver modifies the action of the parts, so as to induce that form of inflammation which Mr. Hunter has termed the adhesive.

This effect of the nitrate of silver is equally observed in recent wounds, whether incised, punctured, or bruised. In incised wounds, union by the first intention is frequently secured by the application of the nitrate of silver on the surrounding cuticle. In punctured wounds union is promoted, and suppuration prevented. In bruised wounds the action of the parts is so modified that their texture is often preserved unbroken, and sloughing, which would otherwise inevitably have taken place, obviated. I speak in general terms, merely wishing to state, in this place, the fact of this peculiar effect of the application of the nitrate of silver. The various limitations and exceptions of this statement will be pointed out hereafter. In the meantime it must be confessed that this principle — these effects of the nitrate of silver are equally new with those pointed out in the preceding section ; and I confess that I am equally at a loss to account for them. The influence of the nitrate of silver in inducing adhesive inflammation is not less obvious in its application to inveterate ulcers.

In neglected punctured wounds, attended

O OF THE USE OF

by ulceration, pain, swelling, and fungous growths, and in cases in which there would have been destruction of the parts, as in deep-seated inflammation of the finger, the nitrate of silver has a most decided effect in checking the inflammation, in preventing that destruction of parts, and in inducing the healing process.

In ulcers which are rapidly spreading, attended with severe and extensive inflammation, the nitrate of silver has frequently an immediate effect in subduing the inflammation, and in inducing the healing process.

In those cases of inveterate and obstinate ulcers of the legs which have been for years unhealed, attended by sleepless nights and painful days, the nitrate of silver, appliedunder particular regulations, has extraordinary powers in relieving the pain, and inducing sleep, even from the first time of its application ; and eventually in healing the ulcers themselves, and effecting a more firm and durable cicatrix than any other mode of treatment.

The mode of applying the nitrate of silver is somewhat the same in some of these cases as in external inflammation. But each particular case requires its peculiar mode of treatment : this will be best detailed in treating of each of these cases distinctly.

III. Of the Nitrate of Silver as a means of healing by eschar.

1. Of the adherent eschar.

It is a singular and interesting fact, that whenever an eschar made over the surface of a wound or ulcer can be preserved adherent, such wound or ulcer infallibly heals.

It appears scarcely necessary to describe the immediate and well known effects of the application of the nitrate of silver to the surface of a wound or ulcer. It may, however, be shortly observed, that it induces, at first, a white film, which, when exposed to the air, assumes in a few hours a darker colour, and at a later period, becomes of a dark grey or black. As the eschar undergoes these changes of colour, it gradually becomes harder and resembles black 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 it 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 nitrate of silver should be made not only over the whole surface of the wound, but also upon the surrounding skin ; for the eschar in drying is apt to contract a little, and in this manner might leave a space between its edges and that of the adjacent healthy cutis.

It is sufficient to apply the nitrate of silver lightly over the wound, so as to touch every part of it, and, if there be any surrounding inflammation, the skin should be moistened with a little water, and the nitrate of silver passed once lightly over it.

The importance of avoiding all causes which might detach the edges of the eschar, will be at once apprehended by the interesting

THE NITRATE OF SILVER. II

observation already mentioned, which I have deduced from very extensive trials ; — 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 circumstance 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 wound, 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-beaters 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.

In this manner, 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 consequence 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. In my earlier experiments I often observed this fact ; but since that time I have always applied the nitrate of silver on the surrounding skin and beyond any inflammation which might be present or which might supervene.

I may notice in this place some observations on the comparative effects of healing by eschar and 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 becomes 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 cicatrised. 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 ointment 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.

There is one application of the adherent eschar which I think particularly deserves a trial. In some cases of compound fracture the wound might be immediately and permanently closed by this means. The case will then be reduced to the state of simple fracture, and the advantage of this circumstance must be obvious to every one.

2. Of the unadherent eschar.

The eschar is generally adherent in cases of recent injuries, and very small ulcers, 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 the formation of pus, it may be ascertained in the space of twenty-four hours, by making a small incision into the centre of the eschar, with any sharppointed instrument ; this will give no pain. The fluid is to be gently pressed out, and the nitrate of silver 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 nitrate of silver, as in the former case. Sometimes it may be necessary to make several small incisions in an eschar, if it be rather large. The necessity for this will be seen upon pressure with the point of a probe, as the parts which are not adherent will yield on pressure ; and there may be several such cavities which require evacuating. The healing process goes on best when the orifice thus made is in the centre of the eschar. In this manner the eschar occasionally is rendered adherent ; but more frequently the fluid requires to be evacuated repeatedly ; and this should be done once a day, taking care that the eschar be not needlessly separated by allowing the fluid to accumulate.

If, from accident, the eschar be separated before the ulcer is healed, I advise the nitrate of silver to be applied anew. At length the eschar becomes adherent, and in due time it peels 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. This circumstance occurs from allowing the fluid to remain too long under the eschar without being evacuated. There are pain and inflammation ; the eschar does not separate, but remains long over the sore, and there is no appearance of healing. In this case the whole must be removed by the application of a cold poultice for two or three days ; this plan has not only the effect of removing the eschar, but of allowing any inflammation or irritation to subside ; afterwards the nitrate of silver must be reapplied as before.

The gold-beaters skin is more useful and necessary, 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 the nitrate of silver.

The pain experienced on the application of the nitrate of silver 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 ; but the pain in every case soon subsides, and the patient enjoys greater ease than would be experienced under any other mode of treatment. Little or no pain is caused

c on applying the nitrate of silver, after evacuating the subjacent fluid of an unadherent eschar. Altogether the pain inflicted by the nitrate of silver is less than is generally imagined, and scarcely forms an objection to its employment. It may be proper, in the last place, to notice such circumstances as render these modes of treatment inapplicable. It is improper to employ the nitrate of silver with a view of healing by eschar, in large ulcers, or wounds which do not admit of the formation of a complete eschar, or where the ulcer or wound 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 bed.

3. Of the eschar and poultice.

In some cases there is no chance of effecting an adherent, or even an unadherent eschar. The size or situation of the wound or ulcer may preclude the possibility of this. In such a case, the cure may often be effected by first applying the nitrate of silver, and then a poultice ; and this from day to day, according

THE NITRATE OP SILVER. 19

to circumstances, until at length, by the subsidence of the inflammation, and the cicatrization of the ulcerated surface, the case may admit of the formation of an adherent eschar, and of the final healing of the ulcer.

This plan is particularly useful in cases of neglected punctured wounds, attended by ulceration, pain and swelling ; and in cases of recently-opened abscesses. By this mode of treatment the pain and swelling are much subdued, and a free issue is secured for the secreted fluid ; and in no case have I seen the original inflammation increased.

I have seen many cases in which, by this mode of treatment, much suffering, and perhaps the loss of some of the smaller joints, have been prevented, in deep-seated inflammations of the fingers, which, having been neglected, have issued in severe inflammation, and terrible fungous growth. In these cases it is not only necessary to apply the nitrate of silver to the surface of the sore, but in every cavity, or orifice, which may be formed by the disease, and also on the surrounding inflamed skin, repeating it as may be necessary.

Chapter II. Of The Use Of The Nitrate Of Silver

IN THE TREATMENT OF EXTERNAL

INFLAMMATIONS.

I. Of Phlegmonous Inflammation.

The effects of the application of the nitrate of silver in the cure of phlegmonous inflammation will be best understood by reading short details of individual cases. I shall therefore proceed to give such a selection of these as appear to me best calculated to elucidate this subject.

Case 1. — Miss , aged 21, of gross

habit, was seized on Saturday with acute pain across the patella, whilst sitting at dinner, without any previous known cause. On walking a short distance she found that she was lame, and that her knee was stiff. Half an hour afterwards the knee was observed to be swelled, but there was no redness. A poultice was applied. In a few hours more, inflammation was observed to be spreading up the thigh ; the poultice was taken off, and soap liniment was applied.

On the following morning the poultice was applied, and it was continued all day, and until Monday, when I saw her. The inflammation had spread along a third part of the length of the thigh, and downwards, nearly to the ancle ; the limb was much swollen, exceedingly hot, and a slight fluctuation was felt just below the patella. I applied the nitrate of silver over the whole surface of the inflamed parts, and did not open the abscess, as I knew from experience, that the tumour would subside, rather than increase, soon after the application of this remedy. I directed an emetic and purgative medicine, and desired a fracture cradle to be put over the limb, which was kept exposed.