Elements of Surgery. Robert Liston

the age, strength, and constitution of the patient. In the greater number of cases in young subjects, after the stomach and bowels are unloaded, the system must be supported by tonics and nutritious food; none are more beneficial than the preparations of iron.

      When the occurrence of anchylosis affords the only hope, this process ought to be encouraged by rest, and the limb at the same time kept in that position which will be most useful in after life; this will be effected here also by the employment of splints.

      In cases of disease of the knee, ankle, elbow, or wrist joints, notwithstanding everything that can be done, the disease often runs its course, abscesses form and give way, the patient’s health declines, and he becomes emaciated and hectic. In such cases amputation, when not contraindicated by internal disease, must be had recourse to, as the only remedy. In some few instances, the excision of the diseased extremities of the bones may supersede this operation; but this will be discussed in a future part of the work. Every circumstance must be well weighed before mutilation be resorted to; and there can be little doubt that thousands of limbs have been saved by the employment of the means above mentioned, which would have been otherwise doomed to amputation.

      Hydrops articuli will in general be got rid of by the use of friction, either dry or with liniments; by stimulating plasters or by blisters; and by the proper application of bandages. Mercurial ointments are used in this affection, and often with very great benefit. Electricity has been recommended.10

      In neuralgic affections of joints, it is clear that the symptoms are to be combated by general and not by local means, at least of a severe nature. The patient must be amused and occupied, exercise in the open air must be enjoined, and attention paid to diet. The state of the digestive organs and secretions should be looked to, and corrected if need be. Medicines directed to the regulation of the functions of the uterus are essential in the majority of cases. When there is reason to suspect the lodgement of sordes or worms in the intestinal canal of children so affected, the balsam of copaiba, in doses of Ʒss., or more, on an empty stomach, followed, if need be, by brisk purgatives, will be found to answer admirably. Tonics, such as preparations of iron, of quina, &c., are then given with advantage: many apparently bad cases yield at once to such treatment.

      As local applications, anodynes, fomentations, or cold lotions are employed, according to circumstances. Frictions with gently stimulating liniments, belladonna, veratria, &c., may be used as occasion demands. The patient must be encouraged to use the affected limb as much as possible; and the use of all severe and heroic remedies, as bleeding, blistering, counter-irritation, setons, issues, or moxas, discountenanced.

OF INFLAMMATION OF BONE, AND DISEASES THENCE ARISING.

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      Bones grow and are nourished by the same means, and are subject to the same laws, with other parts of the system. Like all the tissues of a white colour, particularly when their growth is completed, they are less freely supplied with bloodvessels and nerves than other parts. When incited action of the bloodvessels occurs in the harder textures, sensibility is roused to an exquisite degree, and the healthy and perverted processes often advance with great vigour and amazing rapidity.

      Inflammation of bone often arises from external injury, and in some constitutions from very slight causes. Its occurrence is supposed to be favoured by a syphilitic taint, but the inflammatory disposition is much more frequently produced in a system vitiated by the abuse of mercury. From the unyielding nature of the tissue, the pain attendant on inflammatory action is dreadfully excruciating; it is also most violent during the night, even in chronic cases, a circumstance which does not admit of satisfactory explanation. The integuments over the inflamed bone are swollen, and the tumour is œdematous; whilst a hard and solid tumefaction exists in the more deeply-seated parts, caused partly by enlargement of the osseous tissue and partly by effusion of lymph into the cellular substance. The bone is imbedded in a gelatinous or lymphatic effusion, situated mostly beneath the periosteum. This membrane is more vascular than in its natural condition, thickened, and at the same time opened out in texture. The bloodvessels of the affected bone are much increased, both in activity and in size; and, in consequence of enlargement of the vessels, and thickening of the naturally delicate membrane on which the vessels ramify, the bone is swollen and increased in size; its texture, as shown in the annexed cut, is loose, somewhat resembling the cancellated structure, and its surface is occupied by numerous foramina, which are enlarged in proportion to the size of the vessels which they contain. The limb is often enormously swollen and indurated. The gelatinous effusion beneath the periosteum speedily becomes organised, nodules of osseous matter project into it, and adhere to the surface of the bone frequently by a narrow neck; these increase in number, gradually assume a solid appearance: the bone is thus thickened, often to a very great extent.

      It has been supposed that the new osseous matter is deposited by the vessels of the soft parts and of the periosteum; but there can be little doubt but that it is secreted principally by the vessels which ramify within the substance of the bone, and by the vessels of the periosteum after they have entered the osseous tissue. Thus, in the case of fracture, the new osseous particles lie between the periosteum and bone at a distance from the broken ends, where the vessels are enlarged and increased in activity, or adhere to fragments which have been detached in part and retain their vitality, but not to the under surface of the periosteum. There is no doubt that thin laminæ of bone are now and then found attached to the periosteum, or impacted within its substance; but this is to be attributed to that morbid action of the tissue, to which this as well as several other membranes is subject.

      When bone is extensively affected with inflammation, motion is impaired; the muscles being displaced and retarded in their action by the swelling and irregularity of the bone, by effusion of lymph into their tissue and intermuscular spaces, and, perhaps, also, by their partaking, in some measure, of the inflammatory action. Any attempt to move the parts very much aggravates the patient’s suffering. Occasionally inflammation attacks almost all the bones in the body, and causes great constitutional disturbance, by exhausting the powers of life: it sometimes terminates fatally. Bones become inflamed from various causes. However it originates, the action ends, as in the other tissues, in resolution, suppuration, or mortification. The effusion by which the diseased vessels naturally relieve themselves in softer textures cannot here take place so readily, or to such an extent as to prove beneficial: the intensity of the action is with difficulty subdued, and, consequently, resolution is comparatively rare. When it does occur, the parts do not soon regain their natural condition, but often remain considerably swollen and indurated, as is seen in nodes, which continue during the life of the patient, without causing pain or much inconvenience.

      Suppuration on the surface, or in the centre, and partial or total death of a portion of bone are the most frequent consequences of external injury and incited vascular action; but suppuration in the cancellated texture frequently follows very slight incited action in those of a scrofulous habit. Tubercular matter exists, in all probability, previously, and it leads very often to long continued disease, curable only by operation. The matter may find its way to the surface after long suffering and great constitutional disturbance. Again, it may be confined for months, or even years, the patient suffering from time to time the most excruciating agony. The bone becomes thickened towards the surface by new deposit, as the cavity is increased by ulcerative absorption, and relief is only afforded, a correct diagnosis having been formed, by artificial evacuation of the matter. In many cases small sequestra lie in the cavity; and though the matter escapes naturally, or is evacuated, the patient’s strength becomes worn out, and he perishes, unless the limb is removed. So long as dead portions of bone remain, the discharge cannot cease permanently. Fresh collections are apt to form in the soft parts if the original openings close. It is no easy matter to discover or remove sequestra from deeply seated bones. A section of the femur is represented on the next page, showing a cloaca leading to the cavity of an abscess in the medullary canal. The bone is very dense in consistence, and irregular on its surface.

      SUPPURATION IN BONE