Elements of Surgery

by Robert Liston

health becomes undermined by want of sleep and continual suffering; and he may at the same time have relaxation of the mucous surfaces, with increased discharge from them, produced by the same cause as occasioned the affection of the coverings of the bones. He may be subject to a relaxed or ulcerated state of the throat, increased or caused by the slightest exposure; and may have hemorrhage from the nostrils, copious expectoration, mucous stools, &c. The periosteal affection alone is a troublesome and serious complaint.

When the pains are fixed and violent, we are sometimes obliged to give small doses of the bichloridum hydrargyri at first, even though there is reason to think that mercurial medicines, perhaps imprudently or carelessly administered, have brought the constitution into its present morbid condition. The good effects of this medicine are well marked and speedy. The patient is freed from the nocturnal pain, gains flesh, and the swellings subside. It ought not to be resorted to, however, unless in severe cases, when the disease cannot otherwise be successfully combated; and when used, it should not be continued longer than is necessary for the removal of the more urgent symptoms: when the pains begin to yield, it is time to discontinue the medicine. Great care is necessary on the part of the patient; he must industriously avoid exposure to moist atmosphere, and ought to be well and warmly clothed, wearing flannel, chamois leather, or both, on the trunk and extremities. A patient treated with the corrosive sublimate of mercury is perhaps more subject to recurrence of the affection, after imprudent exposure, for a considerable time afterwards, than if simple and less powerful means had been employed. A cure can often be effected by the exhibition of the compound decoction of the woods, with or without antimony. Moderate diet and strict abstinence from wine and other internal stimulants should be enjoined; the patient, soon experiencing the good effects of temperance, is exceedingly willing to restrict himself to a somewhat antiphlogistic regimen.

In cases of violent fixed pains, with swelling and threatening of matter forming, incision may be sometimes practised with relief to the patient, but is not to be had recourse to unless there is a risk of the bone suffering. Local abstraction of blood is advantageous, and may, if necessary, be followed by counter-irritation, as the application of blisters or sinapisms. Friction with stimulating substances, or with opiate liniments, is often useful when the disease begins to yield, the pain and puffiness of the parts being thereby dispelled. The hair should be kept short during the cure, and ought not to be allowed to grow till the scalp is firm and sound.

The disease is often so far advanced that, in spite of the most active treatment, abscess forms in one or more points; and, on the matter being evacuated, the bone is found denuded. Exfoliation is then very likely to take place.

Exfoliation generally follows denudation of the bone by accident, but not uniformly. When the periosteum is stripped off by violent injury, the bone in some cases does not lose its natural colour; granulations arise from the exposed part, and it again becomes covered without any part of its substance having been destroyed. Again, careful removal of the periosteal covering, as in excising a tumour or ulcer by the knife, may be followed by death of the outer table of the skull; small portions only separating in some cases, whilst in others a large part of the bone, and of considerable thickness, perishes. The cranial bones may in part become dead throughout their entire thickness, and separate, either after a severe bruise, or in consequence of inflammatory action following injury or arising from disease. The process of separation is either speedy or tedious, according to the vigour of the constitution. The deficiency is repaired, in a great measure, from the subjacent bone, when its whole thickness is not thrown off. But when the breach is complete, the surrounding parts assume the reparative action; the granulations from the dura mater and integuments coalesce, and a dense membrane fills up the space.

The denuded bone should be kept covered and moist, and for this purpose lint frequently wetted with tepid water is the best dressing: spirituous or greasy applications can do no good. A free discharge for the matter should be afforded, and the wound kept clean. If the exfoliation goes on slowly, perforation in the dead bone may be made at different points down to the living parts, with the view of expediting the process. Exfoliations are sometimes retained by surrounding granulations overlapping their edges and confining them in their situation; or are fixed by atmospheric pressure, after separation has taken place from the parts underneath by the action of the absorbents, in the same way as a boy’s leathern sucker becomes firmly fastened to the stone to which it is applied. In such circumstances a small screw may be fixed into a perforation carefully made in the bone, and thus the dead part may be lifted out without pain or difficulty, when otherwise it might have lain for many weeks, keeping up the discharge. In this way the large sequestrum, represented at p. 240, was extracted from its bed. The powdered red precipitate of mercury may be occasionally sprinkled on the parts surrounding the dead portion, in order that the granulations embracing it may be destroyed, and the part more completely detached. The general health must be all along carefully attended to. Sarsaparilla with guaiac, sassafras, mezereon, &c., is often useful, more especially if pains in other parts continue to annoy the patient. Under such medicines he in general improves very rapidly in appetite, flesh, and strength.

The scalp is sometimes, though rarely, the seat of malignant ulcer. In the early stage the ulceration is not of great extent, and affects only the soft parts; perhaps it is confined at first to the common integument, but is extremely apt to extend to the deeper layers which invest the cranium, and even to the bone itself. It is by no means uncommon to find the cranium very extensively diseased, though the affection originated in the superimposed soft parts. Such ulceration of the bone is of a peculiarly destructive nature; it is a disease of the osseous tissue, corresponding to the most malignant ulceration of the soft parts. The bone around the ulcerated cavity is spongy and soft, its margin is irregular, and bristles with numerous spiculæ; the centre is composed of soft morbid deposit, entangling small portions of bone which have become detached, and flabby, almost lifeless granulations shoot from the distempered mass. Such disease, when the patient does not soon succumb to its virulence, advances to a frightful extent, affecting a large surface, destroying the whole thickness of the bone, and even exposing the internal parts. In a case of this description, which occurred in the Royal Infirmary under my care, the anterior half of the cranium was totally destroyed, the left orbit contained a putrid mass, consisting of the disorganised eye mixed with pus and bloody fluid; the dura mater was exposed, and sloughed at several points, and the unhealthy discharge from the parts lodged on the surface of the brain. In malignant diseases of scalp, as of other parts, the lymphatics become secondarily affected: the absorbents feel hard and thickened, the glands in the neighbourhood enlarge and ulcerate, and the sore thereby formed soon assumes the characters of decided malignancy,—hard everted edges, an angry surface, and fetid thin discharge.

Before the disease has become very extensive in the scalp, and when it is still limited to the superficial parts, it may be removed by the knife; the incisions being made at a considerable distance from the margins of the ulcer, so that those parts which may be supposed to have assumed a disposition to malignant action, may be taken away along with the ulcer. In more advanced cases, it may be necessary that the incisions should extend in depth to the bone; and it may be prudent to insist on a portion of the bone exfoliating, the periosteum being removed, and some potential cautery applied to the exposed surface,—as the alumen ustum, oxydum hydrargyri rubrum, &c. The actual cautery cannot be applied with safety to the cranium. Even where the integuments only are removed, and that to a small extent, and in a proper form, it is vain to think of approximating the parts and procuring union by adhesion; the wound must granulate. There is no difficulty in suppressing hemorrhage; either ligature or temporary pressure may be employed according to circumstances. Mild dressings are to be applied, and proper support afforded. The parts should be kept clean, and for that purpose the surrounding scalp must be shaved repeatedly.