CHAPTER VI. Of Gangrene and Mortification. (Part 1)

CHAPTER VI. Of Gangrene and Mortification. Mortirication is the entire death of a part of the body, gangrene is that state or condition which imme- diately precedes it. It is gangrenous so long as it re- tains sensibility, motion, and warmth, when these cease and it acquires a livid, brown, or black colour, it is mor- tified, or in a state of sphacelus. Mortification is of two kinds: the one is not preceded by inflammation, the other is. 4. Mortification, not preceded by inflammation, may be oceasioned by a variety of circumstances. Interrup- tions to the circulation of the blood, as the application of a ligature to the arterial trank supplying the part, or pres- sure on the large veins by which the return of blood is prevented, as in strangulated hernia. Continued pres- ELEMENTS OF SURGERY. 47 sure en a part of the body, occasions mortification: this is seen in the hips and backs of patients who have been long confifed to ope posture in bed. Disorganization by external violence, intense heat or cold, also produce mor- tification whichés not preceded by inflammation. When mortification from any of these causes commences, the parts become livid, cold, purple, black, lose all sensibili- ‘ty, become covered with vesications, containing a bloody dark serum, and at length putrefy, and emit a fetid smell.* These cases admit of no remedy. A soft bread and milk poultice is to.be applied to prevent the dead parts from becoming hard and dry, and thereby adding to the irritation. If the part mortified be very extensive, the constitution sinks, and death takes place. The use of tonics and stimulant medicines, are necessary in these cases. Peruvian bark, elixir of vitriol, and opium, are . among the most useful. ‘When a part has been exposed to intense cold, the greatest care should be taken to raise its temperature gradually, as it is found invariably to mortify when heat is’ suddenly applied. It should first be placed in ice or snow, afterwards in cold water, and very gradually warmed. In some rare instances, mortification comes on without any evident cause, except extreme debility. I have known an instance of this after a severe attack of yellow fever. This is, probably, not preceded by inflamma- tion. IJ. Mortification in many instances is preceded by in- flammation. 4. It may arise from the violence of the in- flammatory action exhausting the vital powers of the part; or, 2dly, from some peculiarity in the nature of the inflammation. ® The process of “sloughing,” in surgical language, significs the separation of dead and living parts. VOL, I. D 418 ELEMENTS OF SURGERY. 4. “Inflammation is an increased action of that power which a part naturally possesses, and in healthy inflam- mations at least, it is probably attended with #n increase of power. In cases however which are to terminate in mortification, there is no increase of pewer, but on the contrary a diminution of it. This when joined to an in- creased action, becomes a cause of mortification, by de- stroying the balance which oughé te subsist between the. power and action of every part.” (Hunter.) When inflammation has, either not been . properly treated, or has resisted the remedies usually successful, and is about to terminate in mortification, the pain and fever suddenly'ceases, the heat is diminished, the red colour is changed to a dark purple, and the swelling which was tense and hard, becomes softer. ‘The cuticle is elevated in various places and vesications form, filled with a darkish and sometimes a transparent fluid. This gangrenous condition rapidly progresses to a complete mortification, attended with putrefaction. The constitutional remedies for it are all such as by lessening inflammatory action, have a tendency to pro- duce resolution or suppuration. ‘These have been al- ready mentioned in the chapter on inflammation. Where- ever the violence of the symptoms lead to an apprehen- sion of gangrene, the evacuations by bleeding, purging, &c. are to be increased, and carried as far as the state of the system will warrant. The indiscriminate use of evacuating remedies, is how- ever by no means proper. The sudden diminution of strength which frequently precedes mortification, de- mands a very opposite mode of treatment, and here tonic remedies are strongly indicated. Wherever the inflam- matory action suddenly subsides, and with it the symp- tomatic fever, and a great diminution of vigour is per- ceived in the patients constitution, the use of tonics and a generous diet, with fermented liquors, especially wine, \BLEMENTS OF SURGERY. 49 ate to be directed. These remedies have no effect cer- tainly on parts already mortified, but they fortify those which are not, and thereby prevent the progress of the gangrene? ‘The Peruviai bark has long been celebrated for its virtues in this particular case. It is a valuable tonic, but Bas probably no specific virtues, and has done great mischief when adntinistered during an inflammatory state of the system. ‘The encomiums lavished on it at the beginning of the last century, appear to have been extravagant, and surgeons no longer recommend its in- discriminate exhibition in cases of gangrene. When the stomach rejects it in substance, it may be administered in decoction, but it often produces so much nausea, that its exhibition is necessarily precluded. The local remedies which have been used in cases of mortification, are various. In the first place, if there exist any local irritation which has e tendency to keep up the inflammatory action, and thus extend the mis- chief, these are to be r- moved. ‘The application of ca- taplasms and poultices can have no effect on the morti- fied parts except by keeping them moist, or correcting The foetor which exhales, but these are important objects and should not be neglected. A poultice of bread and milk mixed with laudanum ; of linseed, or of scraped carrots well boiled in milk answers in general every purpose, and if renewed once in three or four hours keeps the parts sufficiently clean, but in warm weather when the smell is very foetid, the addition of finely pow- dered charcoal to the poultice of linseed, 3ij. to the pound, has some effect in rendering it more tolerable. A poultice consisting of oatmeal and beer, stirred to- gether until they have a proper consistence, is much used by surgeons with a similar intention. ‘Che ferment- ing cataplasm, with or without the addition of charcoal, is also a useful application. It is made in several ways ; 20 ELEMENTS OF SURGERY. the easiest and therefore the best, is by mixing equal parts of yeast, ftour, and honey—if requisite, powdered charcoal may be added. Certain stimulating applications have been much used ; the various. balsams, resins, aromatics, alkohol, &c. They are in general laid aside. The temperature of the local applications should be attended to; if they are ap- plied too hot, they increase inflammation, and if too cold, they weaken the parts. The temperature should be nearly that of the part to which they are applied, and it must always be light, so as not to offend by pressure. Scarifications, if ever, are very rarely necessary, There can be however no doubt of the propriety of mak- ing punctures through mortified paris whenever there is confined acrid matter beneath them, irritating the living parts; they should never extend into sound flesh. In cases of gangrene from erysipelas, this practice is par- ticularly necessary. Wherever extensive sloughing of the cellular membrane from any other cause, as extrava- sated urine, &c. takes place, they are equally proper, but they should never be used with a view to expose the sound parts, in order to apply local remedies to these. ‘When performed with this view, they occasion great pain and inflammation, and must therefore add to the danger and spread the mortification. The knife should not in general be used with a view to separate the dead from the living parts ; this separa- tion will be readily effected by a natural process institut- ed by the absorbent vessels, and to them it should be committed. When gangrene is situated in one of the extremities, it has been the practice of some surgeons to amputate the member. The dangers attending this practice, and the fatal result of a great number of cases, have induced modern surgeons to lay it aside. ‘When the limb is completely mortified and putrid, and vere ELEMENTS OF SURGERY. ‘et , the absorbents have begun to separate the dead from the living parts, portions of the putrid fles may, be eat to diminish the smell, but this should be done with great @re, so as inno instance to injure the living parts. After’ the whole of the soft parts are separated by the absor- bents, the bones may be sawed through ¢ but it commonly happens that the bone has mortified higher than the flesh, and therefore, the same process of separation by the ab. sorbents must be waited for, so that the only advantage arising from the operatiomis a removal of the inconveni- ence of a putrid and offensive mass, the cure not being at, all expedited by the operation. TI shall conclude this account of the local treatment of mortification consequent to inflammation, by reconp mending in every instance the application of a bliater, large endugh to cover all the sound parts in contact-with the diseased. This remedy was introgleéed into,prac- tiee by Dr. Physick, who was led to apply it from the suecess of blisters in cases of erysipelas. He first em- ployed it in January 1803, and from that time umtil-the | present, has had the greatest reason to be pleased with its effects. A great number of’ cases -have occuared iti various parts of the United States, in which an immedi- ate cessation of-the progress of the garigrenehas been the * result of its application. ' I have witnessed its effects in, a variety of instances, and have no besitation in recom. mending it, in preference to #il other local remedies. . After the first dressing of the blister, it will generally be found that’ the mortification has ceased to progress, and in a very short time the separation of the sloughs commences. 2. Mortification it was observed appears in some cases to arise from something peculiar in the nature of the inflammation which precedes it, independently of its apparent violence. ‘The pustule of small-pox and cat. buncle are specimens of this. * ‘ 2g ELEMENTS OF SURGERY. The inflammation of small-pox pustule terminates by @tcasioning the-death of that portion of cutis vera in which the inflammation was situated. _ Carsuncre. This is a tumour beginning on differ- ent parts ef the body, most frequently on the back ; the pain attending itis very great, and of a burning kind; « the skin itches, and under it is found a very hard gir- + cumscribed tumoer, which becomes of a dark red colour. A kind of imperfect suppuration takes place under the skin, attended with gangrene of the cellular membrane, and,skin; sloughs form, and several openings are thus made into the cavity of the tumour, which discharges a fetid pus. The size of these tumours varies greatly, in some in- stanees, they are small, in others many inches in diam- eter—I have seen them extending quite across the hack. _ In ganeral they occur in advanced life, and in those who . have lived well. When they are very large they often , terminate fatally 5 in those instances where several occur * at onée, they .are also fatal. Carbuncle occasionally forms on the head, or high on the neck, and these éaséa ‘generally terminate unfavourably when they are large. In sound constitutions and in patients not very far ad- * vanced in life, a cure may commonty be éxpecied. , ‘The cure dependg greatly upon the‘state-of the con- stitution, and this must influence our prescriptions: in -gentral great. debility httends, and demands a cordial ‘invigorating diet. Opium smust be given to relieve pain, and the bark and elixir of vitriol may often be used with advantage. * + Asa local remedy, the application of a blister is to be preferred to all others; I have known it produce imme- diate relief of the distressing burning sensation which invariably attends this complaint, and occasion a speedy séparation of the sloughs. As soon as matter fluctuates under the skin, an incision must be made to discharge " ELEMENTS OF SURGERY. es it, and a free passage is to be kept opem fog the evacu- ation of pus and sloughs. A plaster of common basilicon after the blister has been cut is to be applied, and if pouly tices are used, they should be very light and fgequently cignged. . Besides the cases of mortification which have been de- scribed, there is a species of mortification which takes « place in the toes and feet of old persons, whether ornot =~ it is preceded by inflammation, is undetermined ; Hunter thinks it is. : The following account of this singwlar affection is 4- P taken from the writings of Mr. Pott. << It is very unlike to the mortification from inflamma’ tion, to that from external cold, from ligature, or ban. dage, or to that which proceeds from any known and vi- sible cause, and this as well in its attack as in its prp- gress. In some few instances, it makes its appearange * with little or no pain; but in by much the majority of , these cases, the patients feel great uneasiness through the whole foot and joint of the ankle, particularly in the~ night, even before these parts show any mark of dis- temper, or before there is any offer than a small dis- coloured spot on the end of one of the little toes. . It generally makes its first appearance on the inside, « or at the extremity of one of the smaller toes, by a small black, or bluish spot: from this spot the cuticle is al- ways found to be detached, and the skin under it to be of a dark red colour. , If the patient has lately cut his nails, or corn; it is most frequently, though very unjustly set to the account of such operation. Its progress in different subjects and under different circumstances, is different; in some it is slow and long in passing from toe to toe, and from thence to the foot and ankle ; in others its progress is rapid and horribly painful : it generally begins on the inside of each small eo] ELEMENTS OF SURGERY. toe, before i¢ is-visible either on its under or upper part, and when it makes its attack on the foot, the upper part ef it first shows its distempered state, by tamefactiong change of colour, and sometimes by vesication, but wherever it is, one of the first marks of it is a separation or detachment of the cuticle. Each sex is liable to it; but for one female in whom Thaye met with it, I think I may say, that I have seen i in at least twenty mgles.. I think alsp that I have much more often found it in the rich and voluptuous, than in the labouring poor: moré frequently in great eaters, than free drinkers. It frequently happens to per- sons advanced in life, but it is by no means peculiar to oldage. It is not, in general, preceded or accompanied by apparent distemperature either of the part, or of the habit. Ido not know any particular kind of constitution ~ which is more ligble to it than an other ; but as far as my observation goes, I think that I have most frequently ob- served it to attack those, who have been subject to flying -upeertain pains in their feet, which they have called gouts, and but seldom in those who have been accus- tomed to have the goet regularly and fairly. It has, by some been supposed to arise from an ossification of ves- + sels; but for this opinion I never could find any foun- dation but mere conjecture. The common method of treating this distemper is, by _ spirituous fomentations, cataplasms actually and poten- tially warm, by dressings of the digestive kind, as they are called, animated with warm, pungent oil and bal- sams, &c. and, internally, by the Peruvian bark. I wish I could say that this, which, with little altera- tion, has been the general practice, had been most fre- quently successful; but I am, from long and repeated experience, obliged to say that it has not. - Tam sensible, that many of my readers will be sur- .prised at my affirming, that the Peruvian bark will not ELEMENTS OF SURGERY. 25 stop a mortification, a distemper in which for some years, it has been regarded as specific; but I must beg not to be misunderstood: I mean to confine my obser- vation and my objection to this particular species of mor- tification, which I regard as being sui generis: and un- der this restriction I must repeat, that I have seldom, if ever seen the bark successful: in all other cases, where- in it is used or recommended, no man has a higher opi- nion of it; but in this I cannot give it a praise which it does. not deserve. «T believe I may venture to say, that I have tried it as fairly, as fully, and as variously as any man has or can: 1 have given it in the largest quantities, at the shortest intervals, and for the longest possible space; that is, as long as the patients life would permit. I have given it by itself in decoction, extract, and substance: I have combined all these together: I have joined it with nitre, sal. absynth. with snake-root, with confect. cardiac. with volatile salts, and with musk, as different circumstances seemed to require, or