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.
In trifling burns cold applications are generally used—as immersing the
part in cold or iced water. A great variety of remedies are employed,
spiritous, watery, acid, alkaline, cold or hot; some apply a coat of
cotton or flour, some of tar or pitch, and they state that when these
artificial crusts separate, the skin is found healed beneath; in fact,
every practitioner, and almost every individual, possesses a favourite
application for this very common accident. Some have recommended
holding the part to the fire, or plunging it into hot liquid; but this
practice, and all similar, are too severe ever to become general,
when milder means prove equally effectual. Perhaps the most common
applications are, a mixture of lime-water and olive oil, or the ceratum
acetatis plumbi. The vesicles, when left to themselves, burst, expose
an irritable surface, and the acrid discharge from them excoriates
the surrounding skin. Their contents ought to be evacuated by a small
puncture, and the cuticle being left carefully undisturbed, a scab
soon forms, by which the part is protected while healing. In extensive
injuries of the skin, where the cuticle has been altogether destroyed,
finely carded cotton is sometimes applied; it is of use in somewhat
the same way as the cuticle in the former instance, and being a sort
of cushion over the part, prevents it from being irritated by bed or
body clothes, or by the patient’s resting on it. It soon becomes soaked
with the discharge, and must either be frequently changed, or become a
receptacle for pus to putrefy in, and maggots to breed; on account of
these circumstances it is objectionable. Dusting the part with common
flour, starch, or hair powder, is equally advantageous, and much more
convenient; relief is afforded by its immediate application; the parts
are cooled; the flour, absorbing the discharge, is soon formed into
crusts, which effectually protect the surface; and the after-secretion
readily escapes from beneath this, no more moisture being imbibed than
is merely sufficient for the encrustation. The artificial covering
ought not to be removed until completely detached, by purulent matter
accumulating beneath it; then its presence can be of no service, and
its removal is accomplished by fomentation or poultice, and without
pain to the patient; whereas, by pulling off the crusts shortly after
their formation, as some do, whilst they are adherent to the surface,
and protecting it from injury, much pain is given to the patient, the
raw surface is irritated, and made liable to over-action; a useful
application is taken away to make room for another, and, perhaps, not
so congenial. After the spontaneous separation, fresh flour may be
again sprinkled over the suppurating surface, and, if the affected part
is small, it may heal under this application. But when, in burns of
considerable extent, suppuration is fully established, and granulations
have begun to arise, tepid-water dressing, and lotions, are to be
applied as to any other granulating sore; for the reasons already
assigned, the applications require to be of a gently stimulating nature.
In severe cases, there is first extreme depression of the powers
of life, under which patients sometimes sink; but most frequently
this state is obviated by the employment of cordials or stimulants.
But these ought to be administered with caution, for reaction soon
commences, and often increases to well-marked inflammation, requiring
for counteraction low diet, and even bleeding. In such cases gentle
laxatives are preferable to purgatives, as by the latter the patient
is obliged to make frequent movements, and those are always painful.
Stimulants have been strongly recommended, at first powerful, and
afterwards gradually weaker, so as, it was said, to restore the balance
between the affected parts and the system; and the latter is again
to be excited, in order to meet the increased action which the parts
assume. The practice is founded on fancy, and cannot become general,
being in its first part cruel, and in its second absurd. Whilst
debility exists, stimulate cautiously; when over-action ensues, adopt
those measures which are best calculated to subdue excitement; this is
common sense, and the common practice.
During the process of healing, position of the parts ought to be
carefully attended to; contraction of the cicatrices, and cohesion of
opposed surfaces often causing unseemly deformities. Surfaces opposed
to each other, and naturally separate, may be prevented from uniting
by dressing interposed; and contraction of joints is to be guarded
against by keeping the limb extended by splints and bandages. Where
deformity has occurred, the hardened cicatrix which is in fault may
be either divided or excised, and by paying attention to position in
the after-treatment, the evil may be greatly lessened. In the case of
contracted joints, it is not necessary to excise the whole or greater
part of the callous web; simple division is sufficient, if carried deep
enough, through the altered and condensed cutaneous tissue. A horrid
case of deformity is sketched on the next page, and from a very horrid
and atrocious scoundrel, the companion and assistant of Messrs. Burke,
Hare, and Co., the Thugs of the Modern Athens. In such a deformity
the art of surgery could not avail. In others, however, the cicatrix
is not so extensive; it is separated into bands, by the division of
which the position of the head and lip is improved, and the comfort
of the patient much enhanced. In one case, in which I operated with
success very lately, the scar, though extensive, was remarkably soft
and pliable, as much so as the finest kid leather.
[Illustration]
PART SECOND.
OF PARTICULAR SURGICAL SUBJECTS.
INJURIES OF THE HEAD.
_Wounds of the Scalp_ are attended and followed by more dangerous
symptoms than wounds of the integuments on any other part of the
body. This is in a great measure attributable to the nature and
connections of the parts. The subcutaneous fatty matter is condensed,
and closely attached to a firm and unyielding tendinous expansion; and
betwixt these tissues and the pericranium, a loose cellular tissue
is interposed, so as to allow of free motion of the parts. They are
highly vascular, with the exception of the occipito-frontalis fascia,
and between them and the internal parts, as is well known, a free
communication exists. Injuries of these coverings, though at first
apparently trifling, and consequently looked upon as of no importance,
and unattended with danger, often assume a very alarming character.
No injury of the head, in fact, is too slight to be despised, or too
severe to be despaired of.
Punctured and lacerated wounds, more especially those penetrating
all the layers of covering, are frequently followed by violent and
extensive inflammation of all the tissues, with severe constitutional
disturbance, and with delirium and other symptoms denoting functional
derangement of the brain. The swelling is often extensive, involving
the whole scalp, together with the integuments of the face, and
completely shutting the eyelids. In some cases resolution may
be accomplished, but the most frequent termination is extensive
infiltration of purulent matter into the cellular, or even into the
more deep structures, with sloughing of the tendinous expansion.
Collections of matter frequently form in the loose cellular tissue of
the eyelids, when the parts are affected with inflammation, whether
superficial or deeply seated.
As to treatment, after the infliction of an injury, the scalp ought to
be shaved, and the wound cleansed of coagula and foreign substances.
If a large flap of integument is detached, it should be replaced,
and retained as nearly as possible in its natural situation; and
if, for this latter purpose, slips of uninitiating adhesive plaster
and methodical compression prove insufficient, it will be necessary
to employ a very few points of interrupted suture: these, however,
must be removed at an early period, that is, when either adhesion or
suppuration has commenced, and ought, if possible, to be altogether
dispensed with, being apt in this situation to produce injurious
effects by their irritation. Light dressing is afterwards applied.
On the accession of swelling, heat, and pain, the parts are to be
well fomented with a hot decoction of chamomile flowers, or hops, and
afterwards covered with a warm and soft poultice; and should these
symptoms continue, the fomentation ought to be frequently repeated.
Fomentation and poultice are also the best applications when a
day or two has elapsed between the receipt of the injury and the
patient’s application for cure. The constitutional symptoms are to be
moderated, and may in many instances be averted, by the exhibition of
antimonials and purgatives; and by general bloodletting, when demanded
and authorised by the symptoms, and the state of the constitution.
Punctures or incisions are to be employed according to circumstances,
in order to lessen the vascular congestion of the part, and prevent
the formation of matter, to evacuate it if already secreted, or to
relieve inflammatory tension and promote the formation of pus at the
incised parts, where erysipelatous inflammation is threatened, healthy
suppuration in such circumstances often appearing to be critical. In
many unpromising cases of lacerated scalp, when a great part of the
cranium has been exposed, and partially deprived of its periosteum, a
rapid cure has taken place without the formation of much matter. The
detached scalp, though much torn and bruised, ought not at first to be
removed, it being more prudent to leave nature to determine how much
must be destroyed. After the sloughs, if any, have separated, and
granulation has commenced, the loss of substance is rapidly repaired
in this region, more especially when the patient is young and healthy.
General or partial support, by bandaging, is required in many cases, as
by a handkerchief, split cloths, or a roller applied in various forms.
_Wounds of the Temporal Artery_ are either the result of accident, or
made intentionally for the purpose of abstracting blood; and it may be
here proper to make a few remarks regarding this latter circumstance.
When it is wished to take away blood from the head, no one thinks
of opening the trunk of the temporal artery; its anterior branch is
generally chosen. By some the vessel is first exposed by means of a
scalpel, and then opened with a lancet. But preliminary incisions
are altogether unnecessary. The vessel ought not to be cut entirely
through, and the incision should extend obliquely across its course;
and care is to be taken that the external aperture shall be larger than
that in the cellular tissue involving the artery, as thus the blood
escapes freely, and no risk is incurred of its becoming infiltrated
into the surrounding parts. When the branch is of the ordinary size,
a sufficient quantity of blood is readily obtained from it; but if,
from its small size, or a faulty form of incision, blood does not flow
freely and quickly, a cupping-glass may be applied, and its lower
edge slightly raised. This latter precaution is absolutely necessary,
for if neglected, little or no blood can escape, the artery being
firmly compressed against the cranium by the edge of the exhausted
glass. No other mode of cupping ought to be practised on the temples,
for the cupping by scarification is here both unwarrantable and
unnecessary—unwarrantable, because the cicatrised scarifications
leave an unseemly and permanent mark on a prominent part of the
countenance,—and unnecessary, since there can be no occasion for six
or eight incisions when one is fully sufficient. The bleeding may be
readily stopped, after the requisite quantity has flowed, by a small
graduated compress placed over the wound, and retained by bandages,
which surround the head, and are afterwards twisted and brought
under the chin in order to increase the security. If by these means
the bleeding is not readily restrained, the vessel may be divided
throughout its whole circumference, by entering the lancet at the
original wound, and moving its point laterally. Then compression is to
be again employed, by the assistance of which the natural processes for
closing the divided extremities are speedily accomplished.
When this artery has been injured by external violence, the wound of
the integuments is generally large, and the bleeding profuse. In such
cases, both ends of the vessel must be pulled out by means of forceps,
and tied separately; afterwards the integuments are to be approximated
and supported.
Unpleasant consequences sometimes result from the simple operation of
opening the temporal artery, and occasionally also from accidental
wounds of that vessel. The integuments unite, and may soon heal; but,
from the compression not being sufficient, a small quantity of blood
is insinuated into the cellular tissue, which becomes condensed for a
considerable extent around the wound, and ultimately a sac is formed,
which communicates with the ununited opening in the artery, and is
consequently filled with sanguineous clots; in short, an aneurismal
tumour is formed. For the cure of this untoward occurrence, the artery
may be tied between the heart and tumour, as in the case of spontaneous
aneurism; but in consequence of the free inosculation which exists
between the numerous ramifications of the artery, this measure may
not prove successful, and it will be found necessary, either then
or afterwards, to secure the vessel beyond the tumour. But there is
another mode of procedure. From the tumour being generally small and
circumscribed, excision of the whole of it can be effected easily,
and so as to leave but a slight scar: this operation is not liable to
failure, and is not more severe than the first mentioned. After the
removal of the diseased part by elliptical incisions, the two ends of
the artery are to be included in separate ligatures, and the edges of
the wound kept together.
A more troublesome accident sometimes takes place,—ulceration of, and
over, the vessel, with effusion of serous and purulent fluids into the
surrounding cellular tissue, often to a great extent. A profuse flow of
blood bursts from the ulcerated surface, perhaps twelve, fifteen, or
twenty days after the vessel had been opened, and, if active means are
not speedily adopted, the hemorrhage by its recurrence may prove very
dangerous. In such cases compression is of no avail; the bleeding may
be staid for a time by this means, but upon the circulation becoming
again active, fresh hemorrhage must and does take place; the parts
around are separated and engorged more and more, the blood escapes in
alarming quantities, and the patient is saved only by the occurrence of
syncope. To search for, and make a clean dissection of the wounded part
of the vessel in such cases, is impossible. A long and deep incision
must be made through the swollen and diseased parts in the course of
the arterial branch, and a ligature passed under it, on each side of
the ulcerated point, by means of the common curved suture-needle, or
of one in a fixed handle. The ligatures should be at a considerable
distance from each other, in order that they may surround healthy parts
of the vessel; after they have been firmly tied, all risk of further
hemorrhage is gone. Of course the ligatures should enclose as little
as possible of the parts surrounding the artery. A poultice is perhaps
the best application for a few days, and under its soothing influence
the effects of the continued compression, which had been previously
employed, soon subside. The after applications must be varied according
to the appearances which the part presents.