Elements of Surgery

by Robert Liston

The disease generally attacks the hands, neck, face, or shoulders of butchers and others, who carry, or in some way deal in carrion. It has also taken place in consequence of the hand being introduced into the rectum—a veterinary method of removing scybala—of an animal labouring under putrescent disease. A pustule appears on the part affected, containing a serous or a dark-coloured fluid; and the base ulcerates, extending through the skin to the subjacent parts; at first it is accompanied with a pricking sensation, afterwards the pustule enlarges and becomes brown, and the pain is burning and itching. The vesicle when opened, or when it has burst spontaneously, furnishes a few drops of red serum, and the pain is thereby relieved for a few hours. A hard, moveable, and circumscribed tubercle forms, without alteration of the surrounding skin. The bottom of the sore is yellow, greenish, or livid, and the sensation is that of acute heat and erosion. Phlyctenæ spread around. The tubercle becomes black in the centre, and an eschar forms; the patient becomes irritable and languid. The gangrenous point begins to extend, and that alarmingly; great swelling takes place, elastic, red, and shining, more emphysematous than inflammatory or œdematous. The burning pain is aggravated; the patient has a feeling of weight and stupor; great constitutional disturbance follows, there is slow fever, with a small pulse, a dry and brown tongue, and unquenchable thirst; a low muttering delirium ensues, and under these symptoms the patient soon sinks. After death, the fetid body swells rapidly. The disease sometimes terminates fatally in twenty-four hours or less; but generally the patient’s sufferings are more protracted. In the treatment, superficial scarifications are of little avail. The only topical application which can be relied on is a powerful escharotic, applied freely to the part, and at an early stage, before swelling and constitutional affection have been added. By it the parts replete with virus, being immediately deprived of vitality, are soon thrown off. Thus the virulence of the poison is annihilated, it is rendered inert, and is concentrated in the slough, and the surrounding parts are stimulated, and receive vigour of action, which enables them to resist any further inroad, and to detach quickly the mortified substance. For this purpose, the most effectual and convenient escharotic is the caustic potass, but the liquid muriate of ammonia may also be employed. The vesicle is opened, and the caustic applied to the exposed surface; and if necessary, the eschar may be afterwards divided, and the remedy reapplied. In the absence of other escharotics, the actual cautery will prove a valuable substitute. After the separation of the slough, the sore is to be dressed with slightly stimulating applications. Bark, camphor, and mineral acids, are given internally, and the patient is enjoined a light diet, with a moderate allowance of wine.

OF ULCERS OF THE GENITAL ORGANS, AND THEIR CONSEQUENCES.

It were unprofitable to enter here upon the History of Venereal Affections, as it is a subject of no practical utility, still involved in uncertainty, and mystified by disputation. It will suffice to describe the different forms of the disease, and state the treatment applicable to each.

During the last century, and in the beginning of this, much greater ravages were produced by the disease than at the present time; and though this may be, perhaps, partly owing to a change in the poison itself, it is mainly attributable to the mildness of the measures by which it has been, and is, opposed. Every form of the affection, as soon as it appeared, was at one time opposed by a counter poison, mercury; and the practitioner, relying implicitly on this mineral as a specific, and not being fully aware of its dangerous properties, continued to gorge the system with the supposed remedy, subverting the constitution of his patient, making, in many cases, no impression on the disease, but still persevering in the use of a poison equal, if not more potent, than the one which it was intended to destroy. The change of treatment has been propitious to our science and to mankind. But let it not be inferred that mercury now is, or ought to be, entirely dismissed from the treatment of this disease, or from practice generally: often no other means are effectual; but it should always be prescribed most cautiously and sparingly.

The effects of the venereal virus are divided into primary or local, and secondary or constitutional; and these present a great variety in their appearances, characters, and tendencies. They are sometimes modified by the constitution, or by the remedies ordered in the first stage; but there can be no doubt that different poisons exist, producing distinct kinds of ulcers, which again are succeeded by different constitutional affections.

The most common kind of sore is the simple ulcer, at first excavated, in consequence of the process of ulceration continuing; afterwards the ulceration stops, and granulations, somewhat fungous, supply its place, so that the surface is raised above the level of the surrounding parts, and has a smooth, soft appearance; there is no hardness of the edges, and there is no tendency to slough or extend by ulceration. Sometimes it commences in the form of a pustule, which soon gives way, discharging its contents, and leaving an exposed surface, in which the process of ulceration quickly proceeds; but often it arises from simple abrasion of the surface. Different forms of sores may exist on the glans and prepuce at the same time; and it is maintained, that one sore may produce another of a different kind, and the same is asserted with regard to eruptions. The simple ulcer, as well as other sores, is produced by the contact of secretions, generally morbid, but often apparently healthy, with a susceptible surface. Sores, with eruption and sore throat, sometimes appear in one or both individuals immediately after marriage, and probably arise from the acrimony of the female secretions causing tenderness and ulceration of the parts. The application of gonorrhœal matter readily produces the simple ulcer on the glans or prepuce, particularly if an abrasion or rawness existed; and if the matter be allowed to remain on an unbroken surface, a pustule will form, and ulceration follow. From this latter cause numerous sores are produced, separated from each other by sound parts, and not extending into one continuous ulcer; and this condition may have been preceded, on the glans, by a rawness of the surface and a profuse discharge, or by a herpetic eruption on the mucous lining of the prepuce. One man may be affected with gonorrhœa, and another with ulcer, from connection with the same female, the same day or hour; and it is doubtful whether the effect is not similar, in both cases, viz., ulceration; for it is supposed, that in gonorrhœa, the discharge, in some rare cases, proceeds from patchy ulceration of the mucous lining of the urethra, similar to the ulceration usually met with on the glans. In examining women who have communicated infection, very often no sores are found, and but little unhealthy discharge. In short, the simple elevated sore may arise from the application of secretions from an unbroken surface, from inoculation of matter from a similar sore, or spontaneously, from inattention to cleanliness. Sores with elevated surface, more extensive than those of the glans and prepuce, occur on the skin of the penis and scrotum, or in the folds of the thigh; and in women they are often met with in the perineum, or the cleft of the nates. Sores of different kinds arises at various periods after the application of their cause, from a day or two to some weeks, or longer, but the usual time may be said to be from four to eight days. The duration of the simple elevated sore may be modified by various circumstances—by the constitution of the patient, his mode of living, and the attention paid to the affected part. It seldom remains open above a few weeks, but occasionally it may be seen unhealed at the end of several months in those who lead careless and irregular lives. Such ulcers produce, as readily as any other sores, enlargement of the inguinal glands; they are a source of irritation, the effects of which may be extended along the lymphatic vessels, to the cluster of glands through which the absorbents pass, so as to cause inflammatory action, ending in indurated enlargement; or venereal virus from the sore may be taken up by the lymphatics, deposited in the glandular structure, and produce a similar affection. Buboes thus caused are situated in the upper cluster of inguinal glands; if the lower cluster is affected, it is to be presumed that the cause is not in the organs of generation, but in some part of the inferior extremity. From the existence of bubo, nothing can be deduced as to the nature of the poison, or the probable effects to be produced on the constitution; for enlargement of glands in the course of their lymphatics will occur from irritation, whether connected with a mild or malignant virus, or with one totally devoid of any poisonous quality.

From the simple ulcer there arises a constitutional affection, in all respects resembling that which follows gonorrhœa (a disease which will be treated of under affections of particular mucous surfaces); but before attending to this, it will be proper to advert to another form of ulcer, which differs but slightly from the preceding in primary and secondary symptoms. It is a sore with a brown surface, either on a level with, or above the surrounding parts, with defined and elevated edges, with no cartilaginous hardness of base or margins, and with no tendency to spread either by sloughing or by ulceration. Such may occur in the same situation as the simple sores, but they often form on the outer surface of the prepuce, or on the scrotum; and are not unfrequently met with round the orifice of the prepuce, which is a most troublesome situation, as, in healing, they generally produce phymosis. Sores and fissures in this situation are very often kept up by the tense and irritable state of the aperture. The bubo which follows this differs from that caused by the simple sore, in having, after ulceration of the integument, a greater disposition to burrow; and this tendency is more marked where mercury has been employed. From either of these forms of ulcer, it sometimes happens that constitutional affections arise, either during the existence of the sore, or some weeks after it has cicatrised.

The usual secondary symptoms are those attendant on a papular eruption. There is fever, with pains referred to the head, to the joints, chiefly the larger ones, and to the chest, which latter symptom is sometimes attended with dyspnœa. This indisposition is followed by the appearance of a papular eruption, termed lichen, on the face and trunk, the extremities being less thickly studded. The fever subsides in a great measure after the eruption appears and comes fully out; but fresh crops of papulæ may appear, and, in this case, the fever continues little abated until the eruption begins to fade. The eruption consists, in the first instance, of simple elevations or pimples of a red colour, and these do not appear at once, but gradually: so that some have assumed the form of cones, with minute collections of matter in their apices, whilst others are mere elevations of the cuticle. When they fade the spots are of a copper tint, and become covered with thin scales, in consequence of the cuticle desquamating; but this latter appearance can never be confounded with the scaly eruptions following another description of primary sore. In all cutaneous eruptions, attended with any febrile action, there is a tendency to sore throat, with tenderness of the eyes; and this eruption is not exempt from a similar affection: the fauces feel raw and tender, and are pained in deglutition; on looking into the throat, the mucous surface is found red and swollen, and the tonsils are generally enlarged; but there is seldom any breach of surface; and, when this does occur, it is rather entitled to the appellation of excoriation than of ulceration. Occasionally the surface is covered with a thin coating of lymph, and sometimes this is confined to the situation of the mucous crypts, so as to give a false appearance of small sores. As in similar affections, unconnected with any discoverable cause, the lymphatic glands, at the angle of the jaw, are not unfrequently swollen and painful.

Such is the usually mild character of this affection; but if its progress has been interrupted by any means, more particularly by mercury, it assumes a more complicated form, and a less tractable nature. If that mineral is administered in the usual style, and at the commencement, when the fever and other symptoms are high, the patient’s sufferings are all much aggravated. After the fever has subsided, the eruption will often be found to disappear under the use of mercury; but it is extremely apt to recur, as soon as the system has shaken itself free from the effects of that medicine. The mercury produces an irritation, which supersedes the eruption, but by frequent repetition its effects on the system diminish: it at last fails to create an irritation more powerful than the disease to which it is opposed, and, consequently, the eruption does not yield, but during its use is frequently reinforced by fresh crops of papulæ. If the eruptive fever, and advanced stage of the disease, are imprudently and suddenly arrested by the use of mercury, by exposure to cold, or by other means, inflammation of the iris or joints often follows, of a very violent form, and not to be easily moderated. No one thinks of repelling measles or other eruptive diseases, and with good reason, for such practice would almost certainly induce serious affections of internal organs. For the same reason, every precaution must be used to allow this form of eruption to take its own course, while we merely regulate the constitutional symptoms as they obtrude.

Another form of eruption, which occasionally, though much less frequently, results from either of the above mentioned sores, is the pustular. It is preceded by fever, and consists of rather large pustules, separated from one another, and not very numerous. After their apices give way, and the contained pus is discharged, a thin scab is formed, and on its separation a small ulcer is left, which in general soon heals from its margins, leaving a dark-coloured spot to mark its situation. The papular and pustular eruptions are sometimes blended; a few pustules appearing amongst numerous papulæ, or vice versâ. The pustular disease is not of frequent occurrence; and in proportion as it approaches the papular, with desquamation, it becomes milder and more easily removed. In it, as in the papular, mercury proves injurious.