Elements of Surgery

by Robert Liston

Abscesses in the soft parts form one after another, several of the bones are often affected at the same time, superficial abscesses and affections of the joints and bones often take place in other parts, and the patient grows weaker and weaker.

Whilst the surgeon attends to the general health, and employs palliative local applications, nature frequently effects a cure. The sequestrum ultimately separates, or the ulceration gives way to more healthy action. New bone fills up the cavity, the redundant osseous deposit gradually diminishes, the openings in the integuments close, and the swelling subsides. In some rare cases, it may be necessary to take away the offending part, in consequence of the health alarmingly declining.

Collections in the Thecæ of the flexor tendons are occasionally met with. Those of the thumb and forefinger are most frequently affected. The swelling often attains considerable size. The fluid is colourless and glairy, mixed with small cartilaginous bodies of a flattened form, and the size of mustard seeds, or split peas. The swelling sometimes extends under the annular ligament, and under the fascia of the forearm. Alternate pressure on the different parts of the swelling is attended by a very peculiar sensation. Motion of the parts is seriously retarded.

Accumulation of the fluid is not prevented by any means. Puncture has been practised successfully in several instances, in others a good deal of inflammatory action followed. On the escape of the fluid, the motions of the parts are so far regained.

Ganglia are collections in the bursæ, of various sizes, about the wrist. They are situated more frequently on the fore than on the back part. Sometimes they occur, small, on the sides of the fingers. At first they are attended with pain, afterwards with inconvenience only. The swelling is usually globular; but when large, as on the back of the wrist, the form is rendered irregular by the pressure of the tendons. The cyst is generally of considerable thickness, the fluid glairy and albuminous. They present an unseemly appearance, and when awkwardly situated, retard the motions of the limb. Frequently they form without apparent cause; sometimes they are attributed, and perhaps rightly, to a twist or over-exertion of the wrist, like windgall in hard-wrought horses, who have been put to work when young, and before their full strength has been attained. The affection is most frequently met with in females of the lower ranks; in them the structure of the limbs is more delicate than in males, and they are often obliged to use great exertions with the upper extremities before the growth of the body is completed.

Friction is of no use. Continued pressure on the swelling, by coins or small pieces of lead bound down for weeks or months, is very seldom followed by cure. If the tumour is placed over a bone, sudden and firm compression should be made with the thumb, so as to rupture the cyst, or with the same view it may be struck sharply by an obtuse body. The contents are thus extravasated into the cellular tissue, and are speedily absorbed; the cyst inflames, and becomes obliterated. Sometimes the excitement is insufficient for complete closure of the cyst, and the swelling returns. When the cyst is thick, the tumour of long duration, and the person impatient of pain, it may be punctured by a cataract needle of any kind; one thin and double-edged is probably the most convenient. The instrument is introduced through the skin, at some distance from the swelling; and, by moving the point of the needle after penetration, the cyst is divided freely. The needle is withdrawn, and the orifice closed by the finger. The contents are then squeezed into the cellular tissue, and this is followed by the same favourable results as in the preceding method. Removal of such tumours by dissection is unnecessary, and also attended with risk. I have removed several large ones by incision; but the whole cyst can seldom be taken away, and there is great risk of inflammation ensuing, followed by sloughing of the tendons, or by rigidity of the part. From my experience of the unfavourable consequences of incision, I should not again adopt such a proceeding. Setons have been passed through the swellings, but I cannot attest either their efficacy or their safety.

Exostoses of the phalanges of the fingers are rarely met with. Sometimes bony enlargement occurs, involving many of the phalanges along with several of the metacarpal bones. In such cases, both hands are often similarly diseased, and other parts of the osseous system also affected. When the tumour is limited to one or two fingers of one hand, then, to get rid of the deformity and inconvenience, the patient may desire its removal. The whole of the bone affected should be taken away, lest the disease be reproduced.

Spina ventosa, acute or chronic, more frequently the latter, is sometimes met with in the metacarpal bones, or in the phalanges. The same treatment is applicable here, as that already detailed in regard to similar affections of the lower jaw. Amputation above the tumour may sometimes be necessary.

The hands of infants are sometimes found deformed, turned inwards, as the feet are more frequently. Some of the carpal bones are compressed, from the awkward position of the limb, but become properly developed, if the parts are placed in their proper position as soon as the deformity is observed, and kept so. But the displacement is unmanageable if long neglected. Congenital deficiency of the fingers is a deformity and inconvenience, but cannot be remedied. Adhesion of one or more of the fingers, even to their points, is met with occasionally as a congenital affection. Separation is readily accomplished; but the dressing requires to be carefully attended to. Adhesions may result from careless management of extensive abrasion or ulceration, or from a burn, and such are not so easily remediable. Superfluities may be abridged. Some children are born with two thumbs or two little fingers; these have generally only a cutaneous attachment to the rest of the hand, and that is easily divided by the knife or scissors. The redundancy should properly be removed by the obstetrical practitioner, as soon as it is observed.

The Bursa over the Olecranon Process is liable to enlargement, by gradual accumulation of the secretion, in consequence of habitual pressure on the elbow. The contents are either serous or glairy, usually the latter, and the swelling is indolent. But acute swelling not unfrequently takes place in this situation, from external injury; then the tumour is formed rapidly, there is heat and pain in the part, and the integuments are discoloured around; in such cases the bursa is filled with pure blood, or with a sero-purulent and bloody fluid. Inflammation of the bursa often follows bruises and lacerated wounds, and is apt to extend to the forearm and arm; causing extensive and deep effusion, great tension of the parts, and severe constitutional disturbance.