Elements of Surgery

by Robert Liston

In more severe cases, fomentation and copious abstraction of blood by leeching, at a very early stage, may effectually suppress the inflammatory action; but patients seldom apply till after the opportunity for this treatment has passed. When tension has occurred, whether purulent matter has formed or not, a deep and free longitudinal incision must be made, including the affected tissues. This is uniformly followed by great relief, all the violent symptoms subside, and the action is limited; the effusion, if any, escapes, and the affected bloodvessels are emptied—further suppuration is prevented, and the tissues are perhaps saved from destruction. Fomentation and poultice are used till the swelling begins to disappear, and the discharge to diminish; and the hardened cuticle is removed, when detached. The cure is completed by bandaging, and such applications to the wound as its appearance may render suitable. Should inflammation recommence and extend, or abscess threaten in other parts, recourse must again be had to free incision, followed by the treatment already described.

Destruction of the articulating apparatus, with ulceration of the opposed surfaces of the bones, is indicated by indolent swelling around, by unhealthy and profuse discharge, by distinct grating being produced on motion, and by marked and unnatural looseness of the joint. In such circumstances, amputation of the finger above the diseased part is fully warranted. But if the patient is obstinate in refusing to submit, or if he is in that rank of life where stiffness of the finger is of no great consequence, the member should be kept steady in a convenient position, so as to favour anchylosis. By splints and bandaging it is preserved in a state of semiflexion, so that, after the cure by anchylosis, it may not be in the way when the patient lays hold of anything, as it would be were it bent into the palm, nor exposed when the other fingers are bent, as must be the case were it kept quite straight. Still the finger is often very useless—worse than useless—when stiff either from loss of the tendons or from destruction of the joint; and more particularly when its position is awkward. So much inconvenience does it give rise to, that patients, who peremptorily refused amputation whilst the case was recent, often return, after a tedious and painful cure by anchylosis, soliciting removal of the deformed and annoying member. When the thumb, however, is the seat of disease, it is of great moment to save any part of it. A stiff joint in the thumb is of less consequence than in a finger; it can still be brought to oppose the rest of the hand in seizing and retaining hold of objects. To promote anchylosis, the affected articulation must be kept at perfect rest, and for a very considerable time. By pursuing this practice, the thumb, represented at page 397, though in a very bad state, the joint being thoroughly disorganised, was preserved. In severe cases of whitlow, all the fingers, the whole hand, and even the wrist, long remain rigid; but the rigidity is gradually dissipated by friction, and by motion, at first gentle and passive.

Chronic thickening and contraction of the palmar aponeurosis occurs occasionally, and, in some cases, to such an extent as to disable the hand almost entirely. The fingers are permanently bent, the palm is hard, and the integument puckered. The most severe examples which I have witnessed occurred in those who were in the frequent habit of playing keyed or stringed instruments; in others no cause could be assigned. Frictions with all kinds of oils and compound liniments, plasters, ointments, &c., have been tried as remedies for this affection, but in vain. The tendinous slips passing to the contracted fingers have been divided, and the origin of the palmar fascia has been cut across, but without permanent benefit. Indeed I believe the disease to be incurable.

The term Onychia is sometimes, and not without good reason, designated maligna: it is applied to ulceration about the nail. Some of such sores are small, and not indisposed to heal; others are very obstinate. They occur at all periods of life, frequently during infancy. They usually commence in a small and irritable tumour or granulation by the side of the nail, or at its root, with swelling and redness around. This may follow bruises or laceration and removal of the nail, extravasation under it, and various injuries of the part. The disease is also met with in the toes, most frequently the great one, causing much lameness; then it is generally owing to the pressure of tight shoes. In many cases the ulceration is extensive, shreds of the nail projecting through the angry surface; there is considerable loss of substance; the discharge is thin, bloody, acrid, and abominably fetid; the edges of the sore are jagged, and the integuments around are of either a bright or a dark red, according to the state of the disease. Sometimes the bone is exposed, and involved in ulceration; or, instead of having lost substance, it is found of an unusually spongy and open texture, and with recent osseous matter superadded. A violent burning pain attends the disease when advanced; the absorbents are irritated and inflamed, and the glands enlarge along their course. The general health is often impaired in consequence; frequently the disease occurs in those of broken-up constitution, along with sores and eruptions on other parts of the surface, ulcerations of the mucous membranes, and other indications of cachexia.

By judicious exhibition of purgatives, antibilious medicines, and preparations of sarsaparilla, and by regulation of diet, the general health may be improved. The edge of the nail, when in contact with the ulcerated surface, must be removed—more especially when the great toe is affected; not that any undue growth is the cause of the disease, but because the sore, pressing on the sharp edge, produces much pain, and keeps up the morbid action. About one-third in breadth of the nail should be taken away; one blade of strong and sharp-pointed scissors is passed along beneath the nail as far as its root, and by rapid approximation of the other blade the part is divided; the isolated portion is then laid hold of by dissecting forceps, or small flat-mouthed pliers, and pulled away by the root. This should be performed as quickly as possible, for the operation, though trifling, is attended with most acute pain; it is quite effectual, the relief is great, and almost immediate. The nail may also be removed by scraping and paring; but this method is not so effectual as the preceding, and almost equally painful. Afterwards the best application to the ulcerated surface, as to other irritable sores, is the nitrate of silver, either used solid and followed by poultice, or employed in the form of lotion. The remedy is almost specific; very few cases prove obstinate under it. Sometimes it may be of advantage to alternate it with the black wash. In protracted and unyielding cases, removal of the whole matrix of the nail has been proposed; the dissection is painful and tedious, and its efficacy doubtful. When the sore is of a weak character, discharging a glairy secretion, studded with soft flabby granulations, connected with unsoundness of the neighbouring cellular tissue, surrounded by undermined integument, and by considerable boggy, soft swelling, free application of the caustic potass is highly beneficial. When the bone is denuded, and involved in ulceration, the phalanx should be amputated.

Unhealthy children are subject to disease of the phalanges, and of the metatarsal and metacarpal bones, excited by slight injury, or originating without apparent cause. Often more than one bone is affected. There is great swelling of the soft parts around the diseased bone, indolent, and not painful; at first hard and white, afterwards more yielding, and of a dark-red hue at one or more points. Imperfect suppuration takes place, the integuments ulcerate, and the cavity of

the abscess leads to the exposed bone; a portion of this generally dies, and is a long time in separating. Great addition of bony matter is deposited around, in irregularly aggregated nodules; and a large shell is so formed, partially investing the sequestrum. This affection may be termed scrofulous necrosis.

Or the bone does not die, but is exposed and ulcerated superficially; or a considerable cavity forms in its interior, apparently from tubercular deposits and suppurative degeneration of the cancellated structure. The secretion from the ulcerated surface is thin, acrid, and often bloody; and new osseous matter is studded around. The surface of the rest of the bone is unusually open in texture, whilst its interior is condensed, and the cancelli are filled with lardy substance. This form may be called scrofulous caries.