Elements of Surgery. Robert Liston

of bone, resolution must be brought about, if possible; the other terminations are to be prevented by all possible means, since they frequently endanger the limb, and even the life, of the patient, and, at best, never admit of a speedy cure. To promote resolution, blood must be drawn copiously from the part; and general bleeding may also be required, though in some constitutions it cannot be safely carried to any great extent. After local bleeding, fomentations assiduously applied will tend much to relieve the sufferings of the patient. Purgatives, nauseating doses of antimony, and all safe measures likely to subdue the vascular action, must at the same time be adopted. Free incisions through the periosteum sometimes relieve the pain, and cut short the disease, the distended vessels being thereby emptied; but such practice is only a last resource, when the action has resisted all other means, and threatens an unfavourable termination. If, notwithstanding the resolutive means employed, the inflammation proceeds unabated, and suppuration occurs, the effused pus ought never to be allowed to remain on the surface of the bone, but must be evacuated by early incision. Otherwise the pressure of the extraneous fluid will cause absorption of the bone, or detachment of periosteum and superficial necrosis; the absorbed surface will, in its turn, secrete pus, and thus an ulcer will be produced; and, from the vascular action becoming debilitated in consequence of the previous incitation, that ulcer will in all probability degenerate into caries. Much mischief is produced by squeezing and bandaging tightly the inflamed parts, as can readily be understood; yet such practice is frequently adopted after suppuration. By it the inflammatory action is excited anew, the formation of matter is very much increased, and however useful such manipulation may be in stiffness of a joint, or mere swelling of bursæ, and sheaths of tendons, still, in inflammation and abscess of bones or joints it is extremely prejudicial, and from its indiscriminate employment by those ignorant of the profession, many limbs have been destroyed. General chronic periostitis, which is produced by exposure to cold, or occurs after or during mercurial courses, and is often supposed to be a symptom of syphilis, is relieved by the internal exhibition of the bichloride of mercury, or other mercurial preparations, combined with sarsaparilla and diaphoretics. In many instances such an affection will yield to no other treatment; and thus the practitioner is occasionally obliged to have recourse to a somewhat paradoxical practice, that of giving mercury for a disease which seems to have been produced by that mineral.

      In inflammation of the short bones or heads of the long bones, if the action does not yield to topical bleeding and becomes chronic, counter-irritants must be employed. Blisters repeated are often useful in subduing the remaining action, and in obstinate cases small caustic issues are sometimes of service. During the adhesion of the eschar, the best application is a common poultice or water dressing, which, on the separation of the dead part, may be exchanged for any simple ointment, it not being at all desirable in general to check the discharge and heal up the breach of surface. Moxa is sometimes employed to make an issue in these and other cases, but it is not superior in any respect to the potential cautery, whilst its employment is generally very alarming to the patient. The sores following the use of the moxa are in some instances tedious in healing; and this may be ascribed to the vitality of the surrounding parts having been diminished by the application.

      In cases of atrophy of bone, and where there is reason to suspect the scrofulous or tubercular deposit to be going on, the affected part should not be much used, and means taken to give tone to the system. Preparations of iron are often exhibited with advantage. The combination of iodine with iron may sometimes answer. Abscesses should be opened early, so as to prevent extension of the mischief. In abscess in the shafts of the long bones, it is occasionally necessary to make an opening through the outer lamella by the trephine, so as to evacuate its contents. Some instructive cases have been given by Sir B. Brodie, illustrative of the good effects of this practice. I subjoin one out of many from my own hospital practice.

      “W. A., aged 22, was admitted Oct. 26, 1837, under the care of Mr. Liston. He is a policeman of weak conformation. He states that when about six or seven years of age he was first attacked with an aching pain in the right leg, near its middle, and since that period has been subject to three or four attacks every year. These usually were experienced in the spring, during rough, windy, and cold weather, and continued from one to three weeks. The pain was always aggravated at night, and so trifling in the day that he was always able to go about. These attacks ceased to occur when he was between 15 and 16 years of age, and since that time, until last May, he has been free from them. He states that up to about his 16th year the bone of the leg gradually enlarged in its middle portion, but then became stationary, and at the period of entering the police the difference between the bones of both legs was not great; this was about two years ago. Since then he has been accustomed to walk for a considerable length of time daily. During some months he was obliged to do the night work, and then he was much exposed to cold and wet. Last May, while thus engaged, he experienced again an aching pain in the middle of the right tibia; this was aggravated at night; and after a fortnight’s duration, during which it became gradually worse, he was obliged to give up his duties in the police, being unable to continue them any longer. At this time he consulted the surgeon of the subdivision with which he was connected; his treatment was fomentations to the leg and aperient medicine occasionally. Not being much relieved by this, he afterwards ordered the application of leeches on three several occasions, and mercury to salivation. At the end of three weeks he returned to his duty. In the latter part of September he was again attacked with pain during night duty; this pain increased rapidly in severity, and after three nights he was again obliged to leave duty. He was now treated again with the frequent and copious application of leeches at different intervals, and likewise took some pills, which did not affect his mouth. This treatment, with frequent fomentations, was persevered in for a month, but without permanent benefit, and then he was brought to this hospital. Has never had any syphilitic complaint.

      “Present state.—Has an enlargement of the tibia about its middle third, of a diffused character, and which seems to extend a good deal inwards and backwards; in this part he experiences a throbbing and lancinating pain at night; during the day he is in general easy; at night there is considerable heat and swelling in the leg; tongue whitish; appetite good. The following pills were ordered:—℞. Bichloride of mercury, two grains; powder of gum guiacum, two scruples; oil of sassafras, ten minims; extract of sarsaparilla, four scruples. To be divided into twenty-four pills, of which let two be taken three times a day. Apply eighteen leeches to the affected part.

      “Nov. 4. The leeches were repeated; much the same.

      “8. Symptoms as before. As he complains of pain over the eyebrow, with nausea, let the mercury be left off. A variety of constitutional and local treatment has been pursued during Mr. Liston’s absence from the hospital, but without affording any relief; the patient’s nights were passed in great agony, and his general health began to suffer. On the 27th, after consultation with Mr. Fisher, the surgeon to the Police Force, Mr. Liston had the patient carried into the operating theatre. He made an incision along the spine of the tibia of about three inches in extent; another shorter one was made to fall on this at right angles from the inner side. The surface of the bone thus exposed was perforated to the depth of fully half an inch by a small trephine. A very dense circle was removed from the perforation; still the fluid, which was suspected to exist, did not appear. Mr. Liston, encouraged by the intense pain complained of as the process of perforation proceeded, again applied the crown of the instrument, and after a few more turns, brought out a further circle of considerable thickness, and this was forthwith followed by a flow of well-digested purulent matter.

      “28. Complains of no pain comparatively; slept well last night after an anodyne draught; has felt much relieved since the operation; a good deal of matter was discharged from the sore during the night; water-dressing to be applied to the wound.

      “30. Slept well without any anodyne the last two nights. The relief afforded by the operation is felt more now than it was at first. The wound discharges a good deal. A tonic mixture, containing infusion of gentian, sulphate of magnesia, and sulphuric acid, was ordered.

      “Dec. 2. The wound looks florid and clean; granulations are springing up; general health very much improved.

      “4. The