Elements of Surgery

by Robert Liston

In the chronic cases of bursal enlargement, pressure is to be avoided; and by the permanent application of an ammoniacal or of a gum and mercurial plaster, absorption of the fluid may in general be procured—the swelling disappearing as gradually as it arose. If the collection is large and obstinate, repeated blistering may be had recourse to; and if that fail, a seton may be passed through the cavity. But the last-mentioned practice is sometimes followed by more action than is desirable, inflammation of the surrounding cellular tissue supervening, and abscesses forming, perhaps extensive. When the collection is purulent, a free opening is to be made into the bursa, and the case treated in other respects as a common abscess. If indolent swelling of the cellular tissue, and spongy thickening of the synovial surface of the bursa, remain after incision, the application of the caustic potass may be required. In extensive and acute inflammation spreading to the surrounding parts, free incisions are often necessary, along with proper constitutional treatment, in order to prevent destruction of the cellular tissue and skin.

Venesection, at the bend of the arm, is too often resorted to by thoughtless or ill-educated practitioners, to the detriment of the patient; as after accidents before reaction has occurred, in local pains not inflammatory, &c. It is very often had recourse to by those who have no correct ideas of the actions of the animal economy, who have not within their heads a peg to hang an idea upon; or, if they have, they are too lazy to think and to combine their ideas, so as to come to a proper conclusion regarding what is the most proper and judicious course to be pursued in any one case. They follow a routine, and bleeding is too generally the commencement of it.

But venesection is absolutely required in many cases, and must often be the principal dependence of the surgeon for removing or preventing evil consequences. After injuries, when the circulation has been restored, particularly when parts important to life are involved—in the first stage of inflammatory attacks, with violent constitutional disturbance—in inflammatory affection of vital or important organs—in these, bleeding is employed to an extent sufficient to control the action. But, even in such circumstances, the practitioner must be cautious not to push depletion too far, but to stop short at the proper time, so that the life of the patient may not be endangered, nor his health impaired, more by the treatment than by the disease.

Venesection is usually practised on either the basilic or the cephalic vein, or else on the median basilic or the median cephalic. The vein is

made to rise by obstructing the return of the blood by a ligature on the arm, applied not so tight as to prevent the flow in the arterial branches. A vessel removed from the inner side of the tendon of the biceps,—that is to say, not over or near the brachial artery,—is to be preferred. But sometimes none sufficiently large or distinct can be perceived unless in that situation, and then great caution is necessary in making the puncture; the patient’s arm must be held very steady, and care taken that the instrument does not transfix the vein. The branch chosen should also be fixed; one which rolls under the finger is pierced with difficulty. The vessel is secured by the thumb of one hand placed immediately below the point to be punctured, whilst the lancet is held loosely betwixt the thumb and forefinger of the other; and the surgeon should by practice acquire the use of either hand for this and other minor operations, being thereby saved much trouble and awkwardness. The right hand is used for the right arm of the patient, the left for the left. The lancet should be in very good order, not too spear-pointed, fine, and with a keen edge. The blade, placed at right angles with the handle, and held lightly, as above mentioned, is entered perpendicularly to the vessel. The puncture is made deep enough to penetrate the vein, and then the edge is carried forward more than the point, that the opening in the integuments may be more free than that in the vein. The most convenient line of incision is obliquely across. The pressure of the thumb is relaxed whenever a utensil is conveniently placed for the reception of the blood; and the arm is kept in the same position as during incision, that the openings in the integument and vein may correspond. Unless this be attended to, the skin will overlap the puncture in the vessel, and thus the stream will be completely obstructed, or at least the blood will not come away so smartly as at first. The blood may also cease to flow quickly from over-tightness of the ligature, and from threatening of syncope; in the former case the ligature is adjusted, in the latter the patient is placed in the recumbent position. When the superficial veins are emptied, the blood flowing by those deep-seated is to be directed to the wound by muscular action; with this view the patient is made to grasp the lancet-case, or any other solid body, in his hand, and turn it round. If the opening in the integument is too small, the flow gradually diminishes, and at length stops, in consequence of blood being insinuated into the cellular tissue, coagulating, and so forming what is termed a thrombus, which plugs the wound. When a sufficient quantity has been obtained, the ligature on the arm is removed, and pressure made below the wound. The integuments around are washed and dried; and two or three small compresses of lint placed on the opening, one above the other, are retained by a riband or narrow bandage, applied in the form of the figure 8; the bandage should be so tight as to prevent the escape of blood, without arresting the flow towards the heart. The arm should be disused for a few hours; and after twenty-four or thirty-six hours, the bandage may be removed, when the opening will usually be found closed.

Besides puncture of the humoral artery, or of its branches, other unpleasant circumstances may follow this little operation. The thrombus—a small bloody tumour from infiltration into the cellular tissue around the opening in the vein—proves troublesome, as already remarked, by preventing the flow, and may render a fresh opening necessary, either in the same arm or in the other. Afterwards it generally disappears gradually by absorption; or the opening in the integuments may not close, and the coagulum be separated and discharged after some days.

Inflammation and abscess round the opening sometimes supervenes. It is treated by fomentation, poultice, and rest, and the matter must be evacuated by free incision. Inflammation of the surface, with diffuse infiltration into the cellular tissue, is also met with after venesection; the treatment of such an affection is the same as when it occurs in other situations and circumstances.

The symptoms and consequences of inflammation of the vein have been already detailed. The affection is attended with great pain, and with swelling from effusion into the cellular tissue around the course of the vessel; the integuments are inflamed and tense; sero-purulent secretion soon takes place in the infiltrated cellular tissue, both deep and subcutaneous, followed by sloughing, and separation of the skin from its subjacent connexions; even death of the muscular structure sometimes ensues—the pectoral muscles have been found black and soft. The local treatment must be active. Incisions are made early into tense parts to prevent internal mischief; and if the vein in the neighbourhood of the wound be filled with pus, it should be laid open freely. The evacuation of the matter affords great relief; afterwards bread poultices or water-dressings are to be applied to the wounds, the other parts should be assiduously fomented, and attention given to the position of the limb. The bowels are to be attended to, and the secretions promoted by mercurials with stimulants, as camphor with calomel, or the hydrargyrum cum creta. When the tongue gets moist at the edges, tonics and stimulants of a more permanent and powerful action are necessary.