Elements of Surgery. Robert Liston

      When the tumour is so situated, or of such a size, as to render the expediency of excision doubtful, it may often be safely and expeditiously removed by ligature. In some cases the tumour is prominent, so that it readily allows of the application of a ligature around its base; in others, it is flat and broad; in which case, a long needle, or needles, armed with a double ligature, can be passed beneath it, and the ligatures can then be separated, and so disposed as to cause sufficient constriction of the entire mass.—Vide Practical Surgery, p. 331, 336. In many cases, incisions may be made with great advantage, either before or after introducing the ligatures; the diseased mass is thus more effectually included and strangled, and much pain and deformity are avoided. The disease, however, occasionally occupies such situations as are totally beyond reach. The application of potass has been recommended; and this caustic is certainly sufficiently powerful to destroy the diseased parts; but its use is attended with danger from profuse hemorrhage. Superficial nævi may occasionally be got rid of by the application of nitric acid, but it requires to be applied over and over again; and, after all, some more effectual means must probably be resorted to. Stimulating injections into the substance of the growth have been sometimes employed. Cures, it is said, have followed the use of setons, or the repeated puncturing and breaking up of the tissue with a needle. None of these means are to be depended upon. The cases are innumerable in which I have been obliged to employ the ligature in an effectual manner, combined or not with incision, where caustics, injections, puncturings, setons, and even imperfectly applied ligatures, had been previously resorted to in vain. Besides, in children there is as much resistance and crying, and as much anxiety in parents, produced by a slight operation, as by a more effectual one.20

OF INFLAMMATION OF VEINS.

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      Veins are very susceptible of inflammation, and the action is very apt to extend along the coats rapidly; in some cases it reaches the right side of the heart, producing most violent symptoms, and speedy dissolution.

      Inflammation in the venous, as in the other tissues, may terminate in resolution. Otherwise, lymph is secreted, whereby the coats of the vessel become thickened, and its internal surface agglutinated, causing obliteration of the canal to a greater or less extent. Suppuration also occurs, and the pus may be deposited in a cyst formed amongst the coats of the vessels; or, as is most frequently the case, it is secreted from the internal coat, and occupies the canal of the vein. It then generally accumulates, its passage into the circulation being prevented by a deposition of lymph sufficient to occupy the calibre of the vessel betwixt the heart and the seat of the purulent matter. The termination in purulent secretion is accompanied with a high degree of constitutional irritation, and typhoid symptoms, more especially if any pus finds its way into the circulation.

      The integuments in the course of the inflamed vessel or vessels are of a dark red colour, and great pain is caused by pressure. Often there is a considerable œdematous swelling of the limb, occasionally followed by the formation of unhealthy pus, diffused in the cellular membrane, causing sloughing of that tissue, or of the soft parts more deeply seated.

      This disease generally follows an accidental wound or operation, as venesection or amputation; it is also of frequent occurrence after the application of a ligature to the extremity of a vein. Many patients have died of this disease, induced by the application of a ligature to the vena saphena major, for the cure of varix. Wounding of large veins ought to be studiously avoided; and if wounded, the bleeding from them should, if possible, be arrested by pressure. When from any cause the extremity of a large vein in a wound is not closed, when it is not plugged up by plastic matter, pus seems to enter it readily, and by mixing with the circulating fluid causes dreadful mischief; great constitutional disturbance accompanies the purulent deposits which follow in the solid viscera and in the joints.

      Inflammation of veins is a very unmanageable disease; the exhibition of purgatives and antimonials will be prudent, in order to evacuate the bowels, produce diaphoresis, and diminish the force of the circulation; the pain will also be much relieved by the application of warm fomentations to the affected part. General depletion is not admissible unless at the very commencement of the disease, and local bleeding must be had recourse to with very great caution; for by copious abstraction of blood, gangrene may be induced, or at least hastened. The limb must be altogether disused and elevated, the patient being kept in a state of complete rest, and not exposed to any excitement or anxiety. Blisters have been employed, but with no good effect. If the vein is much distended, and it is evident that it contains a confined accumulation of pus, it ought to be treated as a common abscess, the matter evacuated by an incision, and various dressings employed, according to circumstances. Such practice I have found successful, and not followed by any untoward symptoms. The abscess is often limited at each extremity by the deposition of lymph in the canal of the vessel; and after the evacuation of its contents, the cavity contracts, and the portion of the vessel which has been the seat of suppuration becomes completely impervious.

      

      Inflammation of a vein is also occasionally followed by the sudden appearance of a purulent depôt in some part of the body, external or internal, at a distance from the inflamed part. Thus, in inflammation of a vein in the forearm, it is not unusual to find an abscess formed suddenly in the axilla on the opposite side; after amputation, or other capital operation, the patient is often suddenly affected with violent symptoms of disease in the chest, and, on examination, abscesses will probably be discovered in the substance of the lungs, the existence of which had only been suspected a short time previous to death. Possibly some pus globules, the seeds of disease, may be arrested in their course through the capillaries of these organs, and thus a foundation be laid for mischief. A very satisfactory explanation of these phenomena cannot readily be given.

      It has already been noticed, that the softening of coagulated fibrin must not be confounded with suppuration. The fibrinous pulp has commonly been called pus, though erroneously; and when occurring in the veins, as it frequently does, has been generally described as inflammation and suppuration of the vessel. The distinction is important; first, because many of the so-called cases of phlebitis are shown to be of a different nature, and secondly, as to the theory of suppuration, on which subject many writers in this country have been engaged in making commentaries on, and compilations of, the French doctrines, which are not deserving of much regard.

      There exists without doubt a capillary phlebitis, and the vast importance of inflammation, and its consequence in these vessels, will be estimated when their great extent and functions are recollected. It is probably in this class of cases especially that the blood becomes contaminated with pus.

      Veins frequently become dilated or varicose; they assume a tortuous course, appear much enlarged, and present an elastic, soft feel, except in the situation of the valves, where they are more hard and incompressible: occasionally the tortuous windings form a bluish tumour of considerable size. The dilatation of the superficial branches is increased by heat, the skin being thus relaxed, so as to give less support. The limb is swollen and œdematous. The dilatation is generally supposed to be confined to the vessels near the surface, but it appears that the deep-seated ramifications are not exempt from the affection. When a dilated vein becomes inflamed, great pain is felt in the part; the vessel feels like a firm chord, its coats are much thickened, and its cavity proportionally contracted; lymph is effused, and by it the canal may be obliterated to a greater or less extent; a spontaneous cure is thus accomplished. In the lower limbs, the disease is often complicated with ulcers; and as long as the veins remain varicose, the ulcers are almost incurable, or if they are brought to cicatrise, the skin soon ulcerates again, and the disease is reëstablished. The coats of the vessel not unfrequently ulcerate, and blood is discharged in appalling profusion: such an occurrence may even prove rapidly fatal. Sometimes, though rarely, skin thinned by pressure from within gives way without previous ulceration, and profuse bleeding ensues.

      The cause of this affection is obstruction to a free return of the blood; as by tumours, either