Elements of Surgery

by Robert Liston

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.