Elements of Surgery. Robert Liston

the treatment of inflammation, with a view of procuring resolution, our attention must be first directed to the exciting cause: it is, if possible, to be discovered, and removed. Thus, foreign bodies are to be extracted—fractures reduced—strictures divided—unnatural accumulations of fluid withdrawn, &c. In many cases, if the exciting cause is removed, nothing more is required; the inflammation speedily subsides. If the cause cannot be removed, or if, after its removal, the inflammation proceeds unabated, the arterial action must be reduced by general and local abstraction of blood. By general depletion, the action of the whole sanguiferous system is diminished, as well as of those vessels more immediately engaged in the morbid action; but the affected capillaries are still dilated, and less capable than the larger trunks of effective contraction to propel their contents; and are therefore only sufficiently depleted by the local abstraction of blood, by leeches,3 cupping, punctures, or incisions.4 Blood may be drawn either from arteries or from veins. In Arteriotomy, the blood is discharged more rapidly, and its flow is of longer continuance, than from a vein, so that the system may thereby be almost completely deprived of its circulating fluid; and perhaps a more speedy impression may be made on the inflammatory action. One objection to venesection is, that after frequent and copious venous hemorrhage, the internal vessels become gorged with blood, and a disposition to apoplexy is induced.

      But bleeding is not to be had recourse to without due consideration of the age, strength, constitution, and idiosyncrasy of the patient; if employed, it must be modified according to these; and it has already been mentioned, that depletion is not always to be persevered in on account of the presence of the buffy coat.5

      Bleeding is materially assisted in reducing the activity of the circulation, by the employment of saline purgatives, along with nauseating doses of antimony. Diaphoretics are of essential service in promoting the action of the exhalants, and thereby relieving the affected capillaries. The exhibition of opium is frequently advantageous, more especially after depletion, in allaying the painful sensations when severe, and averting reaction, and also in procuring refreshing sleep, when the patient is anxious and restless. Digitalis has been administered, with the view of reducing the arterial action; but it has been fully established, that this medicine acts at first as a direct stimulant, and that it is only after its use has been continued for some time that its effects become sedative.

      The local applications to an inflamed part are sometimes made hot, sometimes cold. The latter will perhaps be at first the more grateful to the sensations of the patient. They are, however, with greater propriety employed before inflammatory action is fairly established, and they act by constringing the superficial vessels with which those more deeply seated sympathise to a certain extent; but warm fomentations are more pleasant and useful when inflammation has really taken place; they relieve the pain more effectually, and at the same time promote the cutaneous transpiration; they relax the surface moreover, effusion is thus encouraged, the deeper vessels are so far relieved of their load, and the pressure upon, and stimulation of, the nerves are thus diminished. After the violence of the symptoms has abated somewhat, the vessels still, however, being loaded with blood, the inflammation in fact having become chronic, stimulants may with propriety be applied directly to the affected parts; these are employed, perhaps, with greatest advantage immediately after the bloodvessels are unloaded by leeching, scarification, or punctures; this practice is borne out by the result of experiment and observation. It is seen, that after the vessels have become dilated, and the blood has stagnated in them through the infliction of injury, or the application of some stimulating substance, that the employment of another and different stimulus immediately causes the contraction of the capillaries, and the renewal of active circulation.

      

      During an inflammatory attack, the patient should be allowed very little food, and what he does receive must contain little nutriment in proportion to its bulk. But in many cases it is unnecessary to enjoin such abstinence, as the patient has no appetite, and refuses food.

      In inflammation of deeply-seated parts, such as the apparatus of some articulations, it is a frequent mode of assisting the completion of resolution to excite inflammatory action in an external, and consequently less vital and important part. This is accomplished by the application of stimuli, caustics, cautery, setons, &c.

      It appears that the stimulating substance produces an incited action of the bloodvessels, or a revulsion, according to the older authors, in the part to which it is applied; and that, consequently, the neighbouring arterial trunks, in order to sustain that incited action, supply the part with a larger proportion of their contents than it usually receives; and the necessary consequence of the stimulated part receiving an additional supply of blood is, that the part originally inflamed receives less. The effect, indeed, seems analogous to that of topical bleeding, with this difference—that it is more permanent. Besides, it determines suppuration on the surface, and so renders it less necessary for the vessels to produce pus in a worse situation—the deeper seated parts.

      But it must be borne in mind, that this method is not to be resorted to in the commencement, or during the active state, of the inflammatory action, but only when that action has begun to decline, otherwise the disease may be much aggravated, instead of being relieved.

      If, notwithstanding all the means employed to procure resolution, the inflammatory action continues unabated, the result next to be desired and accelerated is Suppuration; and with this view, it becomes necessary to change the treatment, both local and general.

      Above all, disuse and a proper position of the affected part must not be neglected. Unless absolute repose is strictly enjoined and attended to, and the return of blood from the inflamed tissues is favoured, very great difficulty will, in the majority of cases, be experienced in removing any of the signs or symptoms of inflammatory action, even by the most energetic means, general or local. This will be more fully insisted upon in the progress of the work.

OF SUPPURATION AS A CONSEQUENCE OF INFLAMMATORY ACTION.

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      It has already been stated, that the blood is stagnated in the capillaries occupying the centre of the inflamed part, as well as extravasated in the contiguous cellular tissue. Pus has long been considered as a secretion; but, from the time of Mr. Hunter downwards, a great similarity between the globules of pus and those of blood has been recognised: the former, however, are spherical, larger, and rougher on the surface, and are not so regular in size as those of blood; their diameter is between 1/2000 and 1/3000 of an inch, although some of the globules may be occasionally seen a little larger or smaller than these measurements. Smaller particles are also detected, the molecules of the pus globules, each of which contains two or three. These molecules are insoluble in acids, soluble in caustic

alkalis, and can be freed from the fibrous capsule in which they are contained, and of which the pus globule is composed, when treated with acetic acid. The appearance of the pus globules and molecules is here shown upon a scale, the squares of which are 1/4000 of an inch. These small particles were pointed out to me by my friend, Mr. Gulliver, nearly two years ago, as constituting an important element in suppuration. It results from his observations that the entire pus globule is composed in its central part of these minute molecules, the diameter of which is from 1/10666 to 1/8000 of an inch, cemented together, as it were, by a superficial deposit of matter possessing all the properties of coagulated lymph. And these minute nuclei constitute a proximate animal principle, possessing such well marked characters as to justify us in regarding them as peculiar in their nature, and essential to the composition of the pus globule. Thus they resist putrefaction with remarkable pertinacity, are very dense, and spherical in form, and are insoluble in some acids which act with facility on albumen, fibrin, or the blood-corpuscle. They are easily seen by treating a little recent pus with sulphurous acid, which so acts on the pus-globule as to render the nuclei distinctly visible through its fibrinous capsule; by sulphuric acid the external part of the pus-globule is quickly dissolved, and the nuclei, somewhat shrunk, are seen in considerable numbers floating separately about the field of vision. The instrument used by Mr. Gulliver