Elements of Surgery. Robert Liston

The parts must be kept in a state of complete relaxation and rest; cold cloths or iced water, allowed to drop or run over the surface by capillary attraction, should be assiduously applied. The patient’s bowels must be freely opened, and he is to be kept on low diet. If inflammatory action occur, bleeding, locally and generally, must be had recourse to energetically, accompanied with warm fomentations to the parts; and, at the same time, preparations of antimony, and other saline medicines, are to be administered internally. If there be reason, from the symptoms, to suspect the formation of matter, the parts ought to be attentively examined, in order to detect its presence; and, when discovered to exist, it must be evacuated without delay. In chronic cases, even local bleeding to any great extent is inadmissible. In some a few leeches may be applied, followed by counter-irritation, with advantage. The employment of counter-irritation is, perhaps, chiefly to be trusted to in the treatment of those more chronic affections of the joints in which, from the painful feelings, there is reason to dread disease of cartilage or bone. Of these, blisters are most in use; though, from my own experience, I cannot much recommend them. Their constant repetition is exceedingly annoying, and the slow progress which is made towards a cure under their use is far from encouraging. Tartrate of antimony, applied in the form either of ointment or of plaster, is generally productive of much advantage, in the first instance, by causing a great degree of superficial irritation, and relieving the internal parts. After the pustules have been fully developed, its use is to be discontinued till the surface be nearly whole, when it is again to be resumed, if the recurrence of painful feelings should demand it. Caustic issues have been much praised, and are occasionally beneficial. An eschar is made by the caustic potass applied to the skin, or by rubbing the bichloride of mercury, or any other caustic, into scarifications made by the lancet: the slough separates, and pus is discharged. Instead of promoting a continuation of the discharge, by applying savine ointment, and inserting foreign bodies, or employing other irritating dressings, it is better, when the sore begins to heal, to repeat the application of the caustic to another part; or, when the issue begins to dry up, to apply for a few hours a pledget of strong antimonial ointment.

      The employment of the bichloride of mercury, though a most efficient escharotic, appears not to be unattended with danger, as in many instances violent purging, with tenesmus and bloody stools, follow its application. When swelling exists without pain, considerable advantage may be derived from frictions and liniments of various kinds, with careful bandaging. No applications can be of the least avail unless the joint be kept completely at rest.

      When there is no pain in the joint, when swelling exists, with or without fluctuation, and there is every reason to believe that the extremities of the bones are not much diseased, a cure may be, in general, obtained by the employment of rest, support, and slight superficial excitement. A practice which has been extensively and rather indiscriminately pursued in diseases of joints and of other parts, in affections of synovial membrane, ulceration of cartilage, disease of bone, and even in cases of necrosis, is here detailed. It is useful in proper cases, very hurtful in others. The joint is well washed with soap and water, and afterwards rubbed with camphorated spirits of wine: it is then covered with an ointment spread on lint, and composed of equal parts of the unguentum hydrargyri cum camphora and the ceratum saponis—in the majority of cases the mercurial ointment would be better omitted—strips of lead, soap, or adhesive plaster are then applied with a moderate degree of tightness round, from two or three inches below the joint to the same distance above it: these are covered with soap-plaster spread on thick leather, and the whole is surrounded with a bandage, which extends from the extremity of the limb. The bandage should be put on as far as the joint, before the plasters are applied. The irritation produced on the surface tends to check the deep-seated action, whilst the compression excites the action of the absorbents to remove the effused fluids, and thus to reduce the swelling: by the joint being kept completely motionless, not the least salutary indication of the treatment, the cartilage and bones, if ulcerated, are placed in a condition tending much to expedite their restoration to a natural state. If they are diseased to such an extent that the process of cicatrisation cannot be expected, a cure by anchylosis is, by these means, much more likely to occur. The dressings may be left undisturbed for the space of a week or two; at which period, and, in many cases, sooner, they will be found much slackened, in consequence of the swelling being greatly reduced. By repetition of the application at intervals, the disease will, in a great many instances, rapidly cease, and the joint resume almost its natural appearance; but the period at which this takes place will be found to vary much according to circumstances. If, however, the plasters produce such irritation as to cause a return of inflammatory action, their use must be discontinued till such action has been subdued by the usual means. If the thickening of the external parts has occurred to such an extent as to cause immobility of the joint, or if partial anchylosis has ensued, the limb may be brought to the most convenient position, the knee nearly, but not quite, straight, the elbow half bent, and so on, by the cautious use of a jointed splint, fitted with an extending screw. The practitioner is not to be deterred from having recourse to the above practice, even when matter has collected and burst externally, for sometimes under its employment the cavities of abscesses contract rapidly. After the swelling and other symptoms of disease have subsided, the joint is to be slightly moved, but with great care; and, by a gradual increase of the movement, the natural motion of the part may be ultimately restored. The great object in treating chronic affections of joints must be to give them support, and prevent motion as much as possible. This is effected pretty well in the articulations, removed from the trunk, by the process above described, modified according to circumstances. The filth and smell arising from the plasters often becomes annoying, and, above all, the eruptions and excoriations produced by them prove so troublesome that the application requires to be discontinued. The principal and most essential indication, that of securing repose to the affected parts, is fully as well obtained by the application of well-adjusted splints. These may be formed of lint soaked in a mucilage of gum acacia, as described in the Practical Surgery, p. 150, or coarse linen may be smeared over thickly with a coating of mucilage mixed with common whiting, and another layer of linen spread over that. This is laid out smooth and allowed to dry; portions of this sheet are cut to the form of the affected joint, and, after being moistened, are applied and retained by a roller. A firm case is thus formed, which may be afterwards lined with lint or cotton wadding, and so reapplied. The most suitable splints of all are made of leather, prepared without oil, softened in warm water, and put on as above described. They are, when they have become dry, pared and well fitted, then lined with wash-leather, and padded as may be required. The employment of these splints gives great relief in cases where further excited action has been lighted up in the joint in consequence of the surface of the articulating cartilage having become ulcerated from its free or attached surfaces, or in consequence of matter finding its way into the synovial cavity from the cancelli in the head of the bone. In cases, also, where the painful sensations have existed from the first, and even before any great alteration in the external form of the joint has taken place, indicating primary ulceration of cartilage, this practice affords immediate relief. These splints are easily applicable to the shoulder or hip-joints; and, in the majority of instances, nothing further requires to be done. It appears that Dr. Physick of Philadelphia had been for many years in the habit of confining the motions of the hip-joint by means of hollowed wooden splints, and his practice was marked by very favourable results.9

      It is seldom that local abstraction of blood is at all required, and its employment in cases of morbus coxarius in weak constitutions, which it generally seizes upon, is very questionable. Neither is counter-irritation called for; and it is only in extreme cases, when the suffering is intense, that small blisters over the fore part of the joint, or a slight drain in that situation, or behind the trochanter, is admissible. The nitrate of silver rubbed on the surface causes vesication and discharge; and its early repetition is often followed by good effects. The tincture of iodine, or a liniment containing sulphuric acid, may sometimes be applied with the same view. There is no doubt whatever, that much of the benefit that attends upon counter-irritation, both in the human body and in the lower animals, is to be attributed to the rest that is at the same time enjoined, and often indispensable. It is thus that the firing and blistering of horses does good in the majority of the diseases of tendons, bursæ, bones, and joints. In some instances, it may be necessary to have recourse to soothing applications, as fomentations to affected joints, and to employ general antiphlogistic means