Elements of Surgery

by Robert Liston

[5] [All practitioners are aware how much the formation of the buffy coat is influenced by extraneous circumstances. Of these the most important are the shape and capacity of the receiving vessel, the degree of motion to which the blood is subjected, and the size of the orifice in the vein. Dr. Belhomme, of Paris, who has minutely investigated this matter in a series of one hundred and fifty experiments, has come to the conclusion that a narrow basin, a large orifice, and a full, rapid stream, in the form of an arch, are the external conditions most favourable for producing the buffy coat. The results of these researches have since been verified by those of Gendrin and other observers, and they are well worthy of recollection, as they are calculated to exert an important bearing on the practice of our profession. See my Elements of Pathological Anatomy, Vol. I., p. 207. A cupped state of the blood most commonly occurs in association with inflammation of the serous membranes and parenchymatous organs, and may generally be regarded as evincive of a high degree of vascular excitement. Still, not too much stress should be placed upon this appearance, as it is sometimes present in states of the system the very reverse from that just mentioned, in persons, for example, who have been repeatedly bled or whose strength has been otherwise very much reduced.—ED.]

[6] [Throughout the Elements, the edition of Practical Surgery referred to is that of 1842. Philadelphia.]

[7] [To prevent mortification blisters have long been a favourite means with American surgeons. The practice originated, I believe, with the late Dr. Physick, of Philadelphia, early in the present century. To do good, they should be large enough to cover, not only the whole of the inflamed part, but a considerable portion of the surrounding surface, and to be kept on until they have produced thorough vesication. Blisters are scarcely less serviceable to arrest mortification, after it has made some progress, but in this case they should be placed in contact with the sound skin, not with the dead, as they cannot, when this is done, be productive of any good.

To expedite the sloughing process, allay the unpleasant fetor, and promote the formation of healthy granulations, I know of no remedy that will answer so well as the nitric acid lotion. It should vary in strength, according to the exigency of the case, from four to twelve drops of the acid to the ounce of water, and a cloth wet with it should be constantly kept in contact with the affected part, taking care to wash it occasionally to rid it of the foul discharges with which it becomes from time to time impregnated. If necessary, a poultice can be placed over the rag. Under this treatment, particularly when aided by the liberal use of carbonate of ammonia, wine, brandy, and other cordials, I have often been astonished to witness the rapid changes that have taken place, in cases apparently of the most desperate character.—ED.]

[8] [In this country no remedy is perhaps more frequently employed in the treatment of erysipelas than blistering. In my own practice I have constantly resorted to it for the last fourteen years, and in no instance has it disappointed my expectations. Not only do I consider it as perfectly free from danger, an objection which has sometimes been alleged against it, but I know of no measure so well calculated to afford prompt and effectual relief. My practice is to apply the blister directly to the inflamed surface, together with a small portion of the healthy skin, and to keep it on until it produces thorough vesication. The vesicles are then opened with a needle, and the part covered with a light emollient poultice or the warm-water dressings. In children, and persons of a nervous delicate constitution, or whose health has been previously much impaired, the blister must be removed in from three to six hours, otherwise serious local mischief may be induced. This treatment, although applicable to every species of erysipelas, is particularly valuable in the phlegmonous form, no matter where situated, whether in the face, eyelids, scalp, trunk, or extremities.

Another remedy which has been extensively employed in this country, is the mercurial ointment, first recommended to the notice of the profession by Dr. Dean and Dr. Little, of Chambersburgh, Pennsylvania. My own experience, however, does not enable me to offer anything in its favour. Indeed, if at all useful, it can only be so, it seems to me, in the milder forms of the complaint: in the more severe grades it should never be resorted to, as it is far inferior to blistering, or scarification, as practised by Mr. Liston. The ointment should be perfectly fresh, and be applied upon soft linen, at least twice a day. Professor Velpeau has recently recommended methodical compression by means of the roller, and from some cases which he has published in illustration of his method it would seem to be entitled to further trial.—ED.]

[9] [Dr. Physick (American Journal of the Medical Sciences, Vol. VII., p. 304) was always in the habit of commencing the treatment of hip-joint disease by the administration of a mercurial purge. The preparation which he commonly used was calomel, of which he gave to a patient from six to ten years two or three grains at bedtime, followed the next morning, unless it should have previously acted well, by a dose of oil. If, after having kept the patient perfectly quiet for a few days, he found the parts inflamed, swollen, and tender to the touch, he abstracted from six to eight ounces of blood, by the application of a sufficient number of leeches. Unless the inflammation was very acute, with a good deal of febrile disturbance, he did not prescribe much reduction in the diet, which was generally of a light wholesome character. His next object was to institute a course of steady and systematic purging, which he regarded as far superior to emetics, fomentations, blisters, setons, and caustic issues, so much employed by other practitioners. The articles which he selected were cream of tartar and jalap, which were given every other day in sufficient doses to procure several copious evacuations. These medicines were occasionally changed, either as they lost their effect, or as the patient took a dislike to them.

Having pursued the above plan for a few weeks, and accustomed the patient to his confinement, the next object was to insure perfect rest to the diseased joint, the most essential item of the whole treatment. To this end, a carved splint, long enough to extend from the middle of the side of the chest nearly to the external malleolus, and sufficiently wide to reach nearly one-half round the parts into which it was to lie in contact, was adapted to the shape of the limb, carefully padded on the inside, and secured by two rollers, one of which was passed round the trunk, the other round the limb from the ankle to the top of the thigh. When the limb is much bent or distorted, it should by no means be forced into a straight position in the first instance; on the contrary, the splint should be angular, to accommodate itself to hollows and projections of the parts, and, as the cure progresses, another less crooked should be substituted. It is rarely that more than two splints are required, though Physick was sometimes obliged to use as many as three or even four in the same case. During the whole treatment the patient should lie upon a hair mattrass, and the apparatus kept steadily applied until all the symptoms of the disease have vanished, which is seldom under twelve months.—ED.]

[10] [The treatment of this affection must be chiefly of a local nature, although it may sometimes be necessary to resort to constitutional means, especially mercurial purgatives. When dependent upon a gouty or rheumatic state of the system, the different preparations of colchicum may be exhibited with a prospect of advantage, as also the hydriodate of potash in large doses. As a local remedy, blistering is by far the most prompt and effectual, and worth all the liniments and unguents that have ever been devised. The discharge from the vesicated surface may be maintained by savin or tartar emetic ointment; or, what is preferable, the fly may be reapplied as soon as the sore becomes dry. The operation of the blister should be aided with a bandage and a piece of oiled silk, or strips of adhesive plaster, to support the distended ligaments. Should these means fail, or the accumulation be so great as to impede the motions of the joint, and render it probable that absorption cannot take place, a small valvular incision may be made into the most dependent situation of the swelling, to draw off the fluid. Such a step, however, although justifiable under the circumstances here indicated, should not be taken without due reflection.—ED.]

[11] [Rachitis is emphatically a disease of infancy, being most frequently witnessed from the eighteenth to the twentieth month; it is occasionally congenital, and sometimes, though rarely, it takes place after puberty. Of three hundred and forty-six cases examined by Mons. Guerin, of Paris,[12] three occurred before birth, ninety-eight during the first year, one hundred and seventy-six during the second, thirty-five during the third year, nineteen during the fourth, ten during the fifth year, and five from the sixth to the twelfth. Of these cases one hundred and ninety-eight were observed in the female sex, the remainder, or less than one-half, in the male.—ED.]