Elements of Surgery. Robert Liston

the making of the punctures may have produced, and keeps the skin perspirable. Under this treatment, every vestige of erysipelas will generally disappear in the course of a few days. In more severe cases, especially in the extremities, the parts must be freely incised. The incisions ought to extend through the integuments and cellular substance, and their length and number must be proportioned to the extent and severity of the affection. One or two pretty free incisions, if made in the proper place, where the greatest degree of boggishness, marking the disorganised state of the tissues, is discovered, will generally suffice—the vast good and the relief afforded depends partly upon the abatement of the tension, in consequence of the evacuation of the effused fluids—upon the unloading of the over-distended bloodvessels of the part, and upon the acceleration of the suppurative process, which is often critical. The constitution is, probably, relieved by the suppuration of the wounds, and the consequent drain of the offending particles.

      Some surgeons have disapproved of long incisions, alleging that they are tedious in healing, and prefer making numerous small ones; but it is difficult to understand how the cure should be more tedious in the one case than in the other, when the actual extent of divided surface is the same. According to my experience, several free incisions are made with less pain than a number of trifling scratches, and heal as soon, whilst by the former the purpose of the practitioner is much better fulfilled: the same good effects result from them as from punctures in the more slight cases, if they are made at the commencement of the disease; and if the affection is in its advanced stage, the effused fluid, and the sloughs, are discharged, and the infiltration of pus, and destruction of parts in consequence of the matter being confined, are prevented by its being allowed a free exit as soon as it is formed. Incisions then are made both in the early stage of the disease, and after effusion has occurred: in the former case, they are justifiable, because they arrest its progress; in the latter, they are absolutely necessary, to prevent its injurious effects. The parts are to be fomented, and afterwards covered with a common poultice, containing no oil or grease, or with soft lint saturated with tepid water, and covered with oiled silk, to prevent evaporation.

      When the erysipelas has gone off, the incisions are treated as common wounds, by dressing and bandage. After punctures, or incisions, more or less blood is allowed to flow, according to circumstances. It often escapes from the vessels of the part in great profusion; this, in many cases, may be prejudicial or excessively dangerous. In the extremities the flow can readily be arrested by elevation of the part, or by pressure, for a short period. In erysipelas of the face, punctures are preferable to incisions, as by the employment of the former the countenance is no way disfigured; if, however, in erysipelas of the scalp, the integuments become swollen, and present a puffy feeling, whilst at the same time cerebral symptoms supervene, free incision or incisions, through the whole thickness of the covering, and in the direction of the fibres, must be made. If erysipelas be thus actively treated, it may be safely affirmed that the disease will not often, unless accompanied with symptoms of putrid fever, terminate fatally; if these means are employed early, the constitutional disturbance will be modified or prevented, and no derangement of the cerebral functions will ensue.

      Powders, such as flour, chalk, and camphor, &c., have been applied to the erysipelatous surface, but are of little use, and, by their irritation, frequently prove injurious on the bursting of the vesicles. They are applied, according to some, with the view of cooling the surface, and after all the part may be seen enveloped in folds of flannel. Cold application, such as the spirituous and evaporating lotions, containing vinegar and spirits, liquor acet. ammoniæ, Goulard’s extract, &c., may, in many cases, afford temporary relief, but their use is fraught with the utmost danger; for their direct tendency is to produce metastasis, and if that be to an internal organ of importance, the result is too generally fatal. Or if the erysipelas, on leaving the part originally affected, attack another also superficial, the local treatment has to be commenced anew. If these lotions are to be employed at all in this disease, they must be made tepid.

      In case of the translation of erysipelas to any important part, blisters may be applied to the surface which it has left, or to any other in the neighbourhood, with the view of recalling the disease to its original and less dangerous situation:8 the actual cautery has even been recommended. In the great majority of cases, however, such means are unavailing.

      In Hospital Erysipelas, purging cannot be carried to any great extent with safety, and general bleeding is seldom if ever admissible unless the patients previously robust and in good health, in whom the disease has occurred in consequence of their being conveyed to a distance and during hot weather, after an accident or wound, and in whom the fever is of a violent inflammatory nature. In civil hospitals, the patients are generally in a weak state before the accession of this disease; and in their case, after the stomach and bowels are regulated, stimulants are more requisite. Great attention must be paid to cleanliness, the sores must be frequently dressed, and the same sponges must not be used for different individuals: in order to prevent contamination by the promiscuous use of sponges, it is better to clean the parts around sores with lint or tow, and to destroy immediately such dressings as have been used. The apartments must be well ventilated, and those who are affected with the disease should be separated from the rest of the patients. The local applications will vary according to the particular circumstances of each case. Strong escharotics may be required to clean the surface of the sores, and put a stop to the sloughing. The nitric acid will answer the purpose well, and is less objectionable than some remedies that have been used; such as the arsenical solution, or the red hot iron.

OF FURUNCULUS AND ANTHRAX.

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      Furunculi, or Boils, most generally occur in unhealthy constitutions, particularly in those individuals who are habitually addicted to the use of ardent liquors: they seem to arise from, at least they follow, disorder of the digestive organs. Their seat is in the skin and subjacent cellular tissue.

      They generally occur in those parts which are possessed of little vitality, as in the back, buttocks, shoulders, the posterior part of the neck, &c. They are seldom single, are often numerous, and vary in size from a pea to a pigeon’s egg.

      A boil is of a conical form, elevated above the surface of the body; its base is hard and firm, whilst its apex is acute, soft, of a white colour, and exceedingly painful; the pain experienced in the tumour is severe and burning. From the comparatively trifling nature of the affection, the assistance of the surgeon is seldom required, and hence the apex of the tumour generally gives way either spontaneously, or in consequence of being scratched by the patient, or rubbed by the clothes; the purulent matter, which is generally small in quantity, and mixed with blood, is thus discharged. This, however, is attended with but little relief in bad forms of the affection; for at the lower part of the cone is situated a considerable quantity of mortified cellular tissue, which must be evacuated before the cavity can heal.

      In this unhealthy species of inflammation, resolution cannot be expected; on the contrary, suppuration is the natural termination of the disease, and must be hastened by poultices and fomentations. A simple or crucial opening, according to circumstances, must afterwards be made in the apex of the tumour, so that the sloughs of the cellular tissue may be permitted to escape readily. In the advanced stage, the sloughs are the irritating cause by which the inflammatory action is prolonged, and on their removal the cavity contracts speedily.

      If there is much derangement of the digestive organ, it may frequently be found necessary to administer an emetic. If the bowels are slow and the liver torpid, calomel and antimony are highly useful, or other mercurial preparations may be given, in combination with active purgatives; if the state of the secretions is more natural, these medicines may be administered in alterative doses. The mineral acids are often usefully administered, with the view of removing the disposition to the formation of boils. Twenty minims of the aromatic sulphuric acid may be given twice or thrice a day in any convenient vehicle. Anodynes are occasionally required.

      Anthrax or Carbuncle maybe considered as a severe form