Elements of Surgery

by Robert Liston

In fact, in all scaly eruptions, whether scaly from their commencement, or having become so in their latter stages and previously to their disappearance, mercury, prudently administered, will be useful by expediting the cure, and not injurious by deranging the system. The tar or citrine ointments may be applied to the eruptions and cutaneous ulcers.

For the ulcers of the throat, unless in a sloughing state, the lunar stone appears to be almost a specific, removing the irritability of the sores, and protecting them from further irritation by coagulating the discharge, which then more effectually covers and protects them. The application requires to be repeated every second or third day, as, by the frequent and necessary motions of the parts, the crust loosens and separates, leaving the surface exposed and irritable. At the same time the sore will contract very considerably under each successive crust. The lunar stone may also be applied in solution; or a solution of the bichloride of mercury in spirits or laudanum may be used, in the proportion of from four to six grains to the ounce, or stronger. The solution of the nitrate of mercury is sometimes employed with advantage. Fumigation of the throat with the red sulphuret of mercury has been extolled as a powerful means of checking the alternating sloughing and ulceration which often accompany the ulcers of these parts, but the propriety of its employment is doubtful; the system is thereby rapidly put under the influence of the mineral, which, as already remarked, generally aggravates the violent disturbance under which the constitution labours. More permanent good may be expected from means taken to remedy the constitutional evils than from such violent remedies as are directed against the affected part, but which also produce a baneful effect on the system. In ulcers of the nostrils, with fetid discharge, snivelling, exfoliation of the inferior spongy bones, affections of the palate, &c., the nitrate of silver is also very efficacious; or the affected parts may be occasionally touched with a hair pencil, dipped in a liniment composed of lime-water, olive oil, and the golden ointment. They ought to be frequently washed with tepid water, and all sources of irritation must be removed. If the patient be in the habit of taking snuff, the practice must be abandoned, and the powder already impacted in the nostrils removed. If there be carious teeth or stumps in the upper jaw, the sores can scarcely be expected to heal till these be extracted, as constant irritation is kept up by them. When the affection proves obstinate, a recourse to mercury is recommended by some writers; but this will make bad worse. Sarsaparilla in these cases, with attention to diet and air, will always prove a better alterative than any form of mercury. It may be combined, according to circumstances, with the nitric or nitro-muriatic acids, or with the hydriodate of potass, in which many practical men have great faith. This medicine is employed in cachexia, following or not the use of mercury, and is directed against eruptions, sore throat, and pains in the limbs.

The constitutional symptoms of the scaly disease, or true pox, when they occur, which is now but seldom, are decidedly benefited by a prudent employment of mercury. It may be administered externally or internally, though the latter method is the one generally adopted. It may be introduced into the system under various forms, according to the particular circumstances of the case, or the ideas of the practitioner. The most common form, and the simplest, is the pil. hydrargyri; but for this may be substituted hydrargyrum cum creta, Plummer’s pill, or calomel with antimony. In painful affections of the bones, with or without swelling, the muriate of mercury (bichloride) is the form which I have found most efficacious; one-eighth of a grain of the muriate being given thrice a day in a pill; or the medicine may be given in solution. The iodide of mercury is also a very useful medicine in some cases. It is impossible, and would be absurd, to lay down any precise rules as to the quantity of mercury which is necessary for the cure of pox: in some patients the system is with difficulty put under its influence, whilst in others a single grain will produce salivation, constitutional disturbance, and eczema. When the mouth becomes affected the mercury ought to be discontinued: much harm and no good resulting from the medicine being pushed to profuse salivation; the tongue swells hideously, the teeth loosen, and portions of the jaw die and exfoliate. It is sufficient that the system be under the influence of mercury; and that circumstance is marked by the tenderness of the gums. If, after the medicine has been disused, the disease does not appear to recede, it may be resumed in the same moderate way as before; but there certainly can be no use in continuing mercury after the symptoms of venereal affection have ceased. Nodes may still exist, portions of bone may be dying, abscesses forming, and various other changes of structure going on, but these are no reasons for a continuance of the mercury. If they have originated from the venereal affection, that cause has been removed, and the diseased actions will now proceed altogether independently of their original cause. Mercury proved beneficial in removing a disease of which they are not a part but a consequence; and, if that medicine be now blindly persevered in, the only effect will be to ruin the constitution, and thereby greatly retard the cure of those affections which, if the natural powers of the system had been merely supported, or in a great measure left to themselves, would have soon ceased to annoy the patient or alarm the antisyphilitic mercurialist.

Slight swellings and pains of the bones often yield to local abstraction of blood, friction, and the internal use of the compound decoction of sarsaparilla. Nodes, however, sometimes continue to enlarge, and occasion much pain, notwithstanding these means; and in such circumstances much relief will be afforded by a free incision over the affected part, from whatever cause the swelling may proceed. When the pain has subsided, and the swelling remains stationary, a decrease of it may be sometimes effected by a blister.[25]

Of the bad effects of mercury on the constitution much might be said. Treatises have been written on mercurial pox, a species reported to be much the most violent; and others have detailed an accumulation of evils, under the title of mercurial disease. There is no doubt that extensive, deep, and sloughy ulcers of the throat are produced by mercury; and of this I witnessed the following unexceptionable instance:—The fauces presented one extensive mass of ulceration, sloughing at its margins, and the uvula was almost detached. The patient was an old and emaciated woman, who neither had, nor could be supposed to have, any venereal complaints. She employed herself in coating mirrors with quicksilver, and to that she ascribed her malady. In fact, her system had been long under the influence of mercury, in consequence of her occupation. When I visited her, her daughter and husband, the latter of whom was paralytic, and almost bedridden, were affected, from the same cause, with a pustular eruption of the face, with disease of the nostrils, and snivelling. Another old woman had numerous and deep ulcers of the fauces, tongue, and lips, having been kept unmercifully under mercury for nine continuous months. She had, besides, taken it from time to time, for upwards of four years, though her sole complaint was slight sore throat. Pains of the joints, too, I believe, are attributable to the use of mercury. That medicine has no power to prevent the occurrence of nodes, for these often form during its action. Affections of the periosteum are very frequent in horses and other lower animals, and also easily excited in some human subjects who have neither had pox nor been put under mercury; but in no instance of venereal disease have I observed serious affections of the bones where mercury had not been given. Even the advocates for mercurialising speak of mercurial nodes. It has been asserted that nodes do not occur when mercury has been given for liver or other complaints; but they do form under such circumstances, though not so frequently as when the medicine has been exhibited during venereal symptoms. A cachectic state is often induced by a continued use of mercurial preparations, or at least by mercury and disease together, in constitutions not originally strong. It is marked by pale lips; bloodless conjunctiva; a rough anserine skin; a relaxed state of the mucous membranes; hemorrhages from these, particularly from the gums, which may prove fatal, as I have myself witnessed; exfoliations of the alveolar processes; slimy stools; pale urine; pains of the limbs; sores, showing great indolence, or even assuming malignant action; dropsical symptoms, and other evils, of which a lengthened catalogue might be made out. Such symptoms were often met with when mercury was exhibited for every trifling or suspected sign of disease arising from carnal conjunction. On this subject, Mr. Samuel Cooper has well remarked: “Experience has fully convinced me, that in no forms of chancre, nor in any other stages of the venereal disease, is it proper to exhibit mercury in the unmerciful quantity, and for the prodigious length of time, which custom, ignorance, and prejudice, used to sanction in former days. Violent salivations ought, at all events, to be for ever exploded. When I was an apprentice at St. Bartholomew’s Hospital, most of the venereal patients in that establishment were seen with their ulcerated tongues hanging out of their mouths, their faces prodigiously swelled, and their saliva flowing out in streams. The wards were not sufficiently ventilated, and the stench was so great, that the places well deserved the appellation of foul. Yet, notwithstanding mercury was thus pushed (as the favourite expression was), it was then common to see many patients suffer the most dreadful mutilations, in consequence of sloughing ulcers of the penis; other patients, whose noses and palates were gone; others who were covered with nodes and dreadful phagedenic sores.” This woful picture is not exaggerated, and cannot be too strongly impressed on the minds of young practitioners. A small quantity of mercury will affect violently some constitutions; as of those who have been in warm climates, or who have taken much of the drug, even in this country.

Eczema Rubrum, a disease resulting from external causes, but which may also be produced by mercury, often arises from but a very small quantity of that medicine even applied externally. It most frequently affects the scrotum and upper and inner parts of the thighs. It is preceded by heat and itching in the part; a diffused redness appears, and the affected surface is rendered rough by the eruption of numerous minute vesicles. In a short time, these vesicles, if not ruptured, attain the size of a pin’s head, and the included serum becomes opaque and milky. The affection soon extends over the rest of the body in successive large patches, and is accompanied with considerable swelling of the integuments, tenderness of the skin, and itching. The vesicles burst, and discharge a thin acrid fluid, which renders the surrounding surface painful, inflamed, and excoriated. The discharge becomes thicker, adhesive, and fetid, and by its drying, partial yellowish incrustations are formed. The disease terminates in desquamation, and in some cases, the hair and nails are also lost. It is preceded and accompanied with smart fever, and general disorder of the system.

Erethismus is another occasional consequence of mercury, characterised by remarkable depression of strength; small, quick, and often unequal pulse; anxiety, sighing, and trembling; a pale contracted countenance, and occasional vomiting. While in this state, sudden exertions are apt to prove fatal.

OF SCALDS AND BURNS.

Different degrees of injury are inflicted on the surface from the application of heated solids or fluids. The term scald is generally confined to the effects of heated fluids, whilst burn denotes the consequences of the application of a heated solid, or of ignited combustible matter; the latter class of accidents is, in general, the more serious, yet the former, though not injuring the skin deeply, gives rise to the most alarming symptoms when a large extent of surface is affected. A slight degree of heat is productive only of redness of the surface, with a sharp hot pain, and these symptoms may subside with or without vesication. However, effusion of serum under the cuticle often takes place almost immediately after the contact of the heated body—the cuticle may be destroyed by the intensity of the injury—or the true skin may die, either partially or throughout its whole thickness, and the subjacent parts be at the same time injured to a greater or less depth. But parts, not severely injured at first, may afterwards perish, violent inflammatory action being excited, which terminates in sloughing. The neighbouring parts have their vitality much diminished, by the direct influence of the injury; and hence, when these parts come to be the seat of increased action, sloughing almost inevitably ensues, from the want of corresponding power. From the same cause, subsequent sores are tedious in healing, being so far debilitated as to be unable to assume full vigour; even slight ulcerations following vesication contract very slowly; the granulations are flabby, and the discharge profuse and thin. The inflammation is often at first very violent, and kept within bounds with difficulty. Burns of the trunk, particularly of the genital organs, are to be considered as attended with much danger. And extensive burns and scalds, wherever situated, are always to be dreaded. Violent constitutional irritation takes place, dyspnœa is apt to occur, with effusion into the chest of serum, or a sero-purulent fluid; and the nervous system ultimately becomes oppressed. Great sinking of the vital powers is generally the immediate consequence of extensive and severe burns; there is shivering, weakness of the pulse, cold extremities, anxiety, and vomiting, requiring the exhibition of warm drinks, and even sometimes of cordials, opium, or strong stimulants. These must, however, be given with a sparing hand, or the depression following the excitement is with difficulty got over. Nor can it be matter of surprise that such serious effects occur, when we reflect on the extreme sensibility, and highly organised state of the affected part, and the important functions which it is intended to perform, as well as those sympathies which it holds with internal parts, on which life principally depends.