varies, in general, according to the severity of the injury. As
was already observed, the part may be immediately deprived of its
vitality—if not, symptoms of gangrene sometimes appear within a few
hours after reaction has taken place; while in other cases, tension,
pain, and heat occur, and may continue for a longer or shorter time,
according to the degree of power remaining in the part. Tension often
exists to a great extent after severe injuries, from extravasation of
blood or serum; the functions of the vessels are thereby interrupted,
and gangrene is inevitable. As the action proceeds, the pain and heat
often subside—the parts become flaccid—dark-coloured serum is effused
beneath the cuticle, forming what are termed Phlyctenæ—the skin becomes
dull and livid—dark streaks extend along the limb, perhaps from the
colouring matter of the blood transuding, as in commencing putrefaction
in the dead body—air is effused into the subcutaneous cellular tissue,
causing a sense of crepitation when pressed by the finger—sloughs form,
either black or of an ash colour—and the gangrene involves a greater
or less extent of the limb. The mortification is here represented as
attacking a limb that had suffered from compound fracture. The dark
part around and above the protruded bone was in a state of sphacelus.
The dorsum of the foot and the integument towards the knee were only
gangrenous. The patient was advanced in life, and the state of the
constitution such as to induce a belief that there was a predisposition
to mortification. The removal of the limb was, under the circumstances,
reckoned inexpedient. In some instances, the mortification is most
towards the surface; in others, it is chiefly amongst the deeply seated
parts. Sudden cessation of pain is generally regarded as an unequivocal
sign of the occurrence of gangrene, especially in the internal viscera;
but it not unfrequently happens that the painful sensations suddenly
cease, whilst no gangrene supervenes, and that a part mortifies, whilst
the pain continues but little abated.
In compound fractures, dislocations, or severe bruises of the soft
parts, dark-coloured, prominent points occasionally appear, in
consequence of the effusion of bloody serum beneath the cuticle; in
these, however, the fluid is speedily absorbed, and the surface resumes
its natural aspect, the cuticle exfoliating and being reproduced;
and it is of consequence to know their real nature, for, if mistaken
for the gangrenous phlyctenæ, the inexperienced practitioner may be
alarmed, and, consequently, have recourse to very injudicious practice.
When the process of gangrene is checked, the skin immediately beyond
the mortified part becomes of a brighter hue, and is affected by a
more healthy species of inflammation, which ultimately terminates
in ulceration, with purulent discharge, and thereby forms what is
called the line of demarcation between the dead and the living parts;
the process, commencing in the integuments, gradually extends to the
deeply seated parts, so that the mortified portion is ultimately
attached to the living merely through the medium of bone or ligament.
Arteries appear more than any other texture to resist sloughing; and
those leading to a mortified part are found contracted and filled with
coagulated blood, so that the spontaneous separation of the sloughs,
and even incisions for their removal, made in sound parts, are followed
by little or no bleeding. This salutary change in the arteries may
be accounted for by supposing, that the inflammatory action which
leads to the separation of the dead substance from the living affects
the arteries at that point as well as the other structures, causing
adhesion of their internal surface, and obliteration of their cavities;
and the natural result is, that the calibre of the artery above
the obliterated point gradually diminishes in size, and the blood
coagulates up to the nearest collateral branch: but in consequence
of extension of the inflammatory action, the collateral branches may
also be obliterated to a considerable extent upwards, and thus the
contraction and coagulation in the larger trunk will also extend in
proportion. Besides, before the line of separation has commenced,
arteries cannot transmit their contents into the sphacelated part, any
more than into an extraneous body; so that the circulation of the blood
in them is as effectually obstructed as if a ligature were tightly
applied; in this way, also, the contraction and coagulation may be
accounted for.
Mortification is accompanied with great anxiety; coldness and
clamminess of the face and extremities; weak, irregular, and hurried
circulation; quick, short breathing; a cadaverous expression of
countenance; hiccup (which, however, often occurs in very slight
sloughing, or when no sloughing has taken place, in external or
internal inflammations, extravasations, &c.); by diarrhœa, vomiting,
and in hopeless cases, more especially of traumatic gangrene, by
delirium and coma; in fact, almost all the symptoms of severe
constitutional irritation are more or less fully developed. In some
cases, the patients are restless and unmanageable; in others, low
and dejected. The disease often proceeds with fearful rapidity to a
fatal termination, the patient becoming comatose from effusion within
the cranium; but in other instances, in which the vigour of the
constitution is greater, and the extent of mischief less, the system
bears up under the affection, and a separation is effected between
the dead and living parts. The danger is in general to be estimated
by a consideration of the size and importance of the part, and of
the age and constitution. The destructive consequences of sphacelus
arise both from a local and general cause; for the mere application of
putrid animal substance to a part still alive—the infiltration, for
instance, of dark serosity into the cellular tissue in the course of a
limb—causes a sort of inflammation attended with symptoms of diminished
power, and followed by constitutional disturbance; whilst the ultimate
extinction of life may be imputed to the effect produced on the system
by the part previously to its becoming sphacelated, and to the sympathy
between the system and the parts which are left in a weak and moribund
condition, and which seem endowed with a disposition to extend the
disease.
In the _treatment_ of mortification, no one would think of using
any means, local or general, so long as the cause remained; and it
therefore must in the first place be removed, otherwise the mischief
may speedily become irreparable; thus, a stricture must be divided,
irritating fluids evacuated, foreign bodies extracted, &c.
In chronic gangrene the cause is constitutional, and the means
employed must be directed accordingly. In general, the power of the
constitution requires support, though, in cases where much fever is
present, it may often be necessary to keep the patient on low diet:
exhibit salines and mild purgatives in the first instance. The effects
of food should be attentively watched, and its quantity increased
or diminished accordingly. On the subsidence of the fever, and when
sphacelus has occurred, wine and animal food must be given abundantly.
Stimulants, strictly so called, are not admissible until the line of
separation be formed, and their exhibition must then be regulated by
the circumstances of the case. Opium and other anodynes are found
necessary during the progress of the disease, to allay irritation and
produce sleep; opium has been recommended on very high authority, that
of Mr. Pott, in mortification of the lower limbs. The bowels must be
attended to. Peruvian bark was at one time supposed to be a specific
in this disease, but experience has not born out the opinion; it
seldom agrees in substance, and the decoction, with or without the
compound tincture or sulphate of quina, will be found much more useful
in supporting the power and tone of the digestive organs. After the
line of separation has been formed, and not till then, the surgeon may
interfere, and assist nature in her work, dividing the exposed bones
or ligaments by which the dead parts still adhere to the living; or
he may perform amputation immediately below the line of demarcation.
Amputation in the sound parts cannot be recommended: for vitality is
impaired throughout the system, and more particularly near and above
the line of demarcation, where, though the structure seems entire, yet
the incisions are made in parts really diseased, and which would almost
certainly and speedily mortify. In fact, amputation above the line of
separation, in whatever way performed, is seldom if ever productive of
advantage in spontaneous gangrene.
In order to prevent the occurrence of gangrene after exposure to
intense cold, the frigid part must be cautiously and slowly restored
to its natural temperature; first by being either placed in very cold
water, or rubbed with snow; afterwards, by the degree of warmth in the
applications, and surrounding atmosphere, being gradually increased.
In acute gangrene, and in robust constitutions, when the affection
arises from over-action, abstraction of blood is had recourse to with
marked advantage. In some cases it may be employed, but with due
caution, even after sphacelus to a slight extent has occurred. In
gangrene, purging and bleeding must not be had recourse to but with the
greatest circumspection; for it ought always to be remembered, that
however strongly they may be indicated, the time is not far distant
when they will be totally inadmissible, and when the weakening effects
of depletion will prove highly prejudicial, particularly in cases where
the mischief is proceeding rapidly.
The loss of blood is frequently beneficial in sloughing phagedena, as
is exemplified on the occurrence of spontaneous hemorrhage in such
cases.
When a portion of a limb, throughout the greater part of its substance,
is so injured that it evidently cannot recover, it ought to be removed
instantly, and before the constitution has suffered.
When gangrene follows inflammatory action, this is first to be
moderated, and then the strength by all possible means supported.
When only a portion of the soft parts of a limb is destroyed by
mortification, and it is likely that the member may be saved and prove
useful to the patient, measures should be adopted to hasten separation
of the dead parts, and reparation of the breach in the living.
After the separation of sloughs has commenced, the attention of the
surgeon is chiefly to be directed towards the constitution; it must be
supported and strengthened by nourishing food, wine, and tonics, or by
stimulants, if necessary. Bark in substance, acids, and other supposed
antiseptics, are of but little use.
The local applications which have been employed are numerous; poultices
of all kinds, charcoal, carrot, and effervescing; various lotions to
the surrounding parts, spirituous applications, such as several of
the tinctures, liniment of turpentine, balsams, &c., with the view of
correcting the fetor. But it is evident that such applications to a
dead part can be productive of no effect; the only beneficial result
that can be expected from such means is removal of the fetid smell,
which can be effected, if need be, by sprinkling a solution of the
chloride of soda on the body-linens and bed-clothes. Scarifications are
sometimes used; when these are made merely into the sphacelated part,
they can be productive of good only by allowing the escape of matter;
when they extend more deeply, they are injurious. This practice,
however, as will be hereafter noticed, is adopted with the best effects
when mortification is threatened.[7]
When the sloughs become loose, they must be removed bit by bit with
scissors; and when the sphacelated part has separated entirely,
the healing of the breach is to be promoted by judicious dressing,
bandaging, and by proper position.
In mortification of an extremity, in consequence of injury, removal
of the part by incision in the sound substance was formerly as much
dreaded as in chronic cases before the separation had commenced; but
such fears have now subsided, and the practice of delay has been in a
great measure relinquished,—amputation being performed in the sound
part, at a considerable distance from the mortified or even gangrenous
tissues, and during the progress of the disease, occasionally with a
favourable result. If the surgeon defer the operation until a line of
separation have begun to form, he will soon discover the danger of
his delay; the constitution will, in the majority of cases, rapidly
sink under the malady before the progress of the disease is in any
measure checked, or any attempt is made to throw off the mortified
parts. Two cases which lately occurred in my hospital practice, are
here introduced from the “_Lancet_,” to show how different the progress
is, and how opposite the practice ought to be. Both the patients made
excellent and rapid recoveries.
“Sarah Arnold, æt. 75, was admitted on the 26th of January. She has
been a person of great mental and bodily activity, and has enjoyed
excellent health from her infancy, until her present illness, although
necessarily exposed, from the nature of her occupation, a gatherer and
hawker of watercresses, to all varieties of weather. About six weeks
ago, without being more than usually exposed to cold, she was seized
with severe rigors. Two days afterwards she began to complain of slight
pain, with clinching of the fingers, which at the same time became
discoloured at the tips, and were partially deprived of sensation.
This at first did not give rise to much uneasiness, and no treatment
was employed; and it was not until a week after the commencement of
the disease, when the discoloration had passed the wrist, and the hand
had become dry and shrivelled, and motion and sensation in it were
completely lost, that a medical man was called in. Both internal and
local remedies were then employed, but without in the least retarding
the progress of the disease, which in about a fortnight from her
seizure had extended a little way above the middle of the humerus,
beyond which it did not pass. At present there is a well-marked line of
separation between the living and the gangrenous parts, but there are
two livid spots beyond it, on the outer side of the arm; on the inner
side, where the disease has extended a little higher up than the outer,
suppuration has already commenced. The integuments in the immediate
neighbourhood of the diseased parts are slightly reddened and tumefied,
and it is there only that she complains of some slight pain. The hand
and wrist are dry and shrivelled, but above this the parts are soft
and flaccid. Below the line of demarcation, the extremity is of a dark
colour, resembling the skin of a negro, and completely deprived of the
power of motion and sensation; but she complains of a disagreeable
tingling, referred to the fingers. The discoloured parts are quite
cold, and the pulse cannot be felt, even in the axilla. Though she
complains much of debility, the system seems to be but little affected.
The appetite is very good; the skin is moderately warm; the pulse is
98, and of good strength; the tongue is moist and clean. She sleeps
little. ℞. _Haust. c. Sol. M. Morph._ gtt. xxv. M. _Vini Rub._
℥iv. Water-dressing to the arm at the line of separation.
[Illustration]
“27. She continues much the same as yesterday; slept little, bowels
moved twice; tongue clean and moist; appetite very good; pulse as
before; heat of skin natural; intellect clear; no expression of anxiety
in the countenance. ℞. _Haust. Con. Vin._ Full diet.
“28. The suppuration on the inner side of the arm is more copious, and
the discharge is more fetid. The livid spots on the outer side of the
arm have not extended, and there is some slight redness around them.
Pulse 104, of good strength; tongue clean and moist; heat of skin still
natural; appetite good; bowels moved once since the last report.
Continue. A little _Sol. Chlor. Calcis_ to be added to the dressing.
“29. The dry and shrivelled state of the extremity has extended as high
as the middle of the forearm. The discharge is much the same as before
in quantity, but is more fetid. The separation between the gangrenous
and the sound parts, which had begun on the outer side of the arm when
she was admitted, is extending a little, both towards the inner and the
outer side. Pulse 90, of moderate strength; skin natural; tongue clean
and moist; bowels open; appetite excellent.
“30. Much the same as yesterday; sleeps a little better.
“31. The suppuration is more copious; the discharge extremely fetid.
The dead parts on the inner side of the humerus are gradually becoming
more detached. No change in the appearance of the livid spots beyond
the line of separation; pulse 102, of pretty good strength; bowels
continue regular, and the appetite is good. Cont. vinum et haust.
“Feb. 2. The separation of the gangrenous parts on the inner side
of the arm has advanced a little more since last referred to. The
livid spots have disappeared, with the exception of the largest,
where a small superficial slough has formed. The diseased parts were
removed to-day, the line of separation being fairly established, and
suppuration having taken place in a great part of its extent. The soft
parts were divided by means of a pair of scissors, cutting as near
to the living parts as could be done with safety; the bone was then
denuded as high up as possible, by passing a bistoury round it, and it
was then divided by the saw. There was no bleeding from the soft parts,
and only slight oozing from the bone, which was found to be alive where
it was divided. Cont. vinum et haust.
“3. Continues in much the same state as yesterday; pulse 104, of good
strength; tongue clean and moist; bowels moved once; skin natural;
appetite good; suppuration very free. Cont.
“5. Suppuration copious; a portion of the dead parts left have
separated, and left a healthy florid granulating surface. Continues
much the same.
“6. Discharge copious, and much less fetid; bowels regular; pulse 100,
of good strength; tongue clean; appetite good; wishes for more food. To
have an additional chop. Cont. alia.
“8. The greater part of the sloughs have separated, and have left a
healthy florid granulating surface; no change in the general symptoms.
Continue.
“9. The stump looks well, and the posterior part of the cut end of the
bone is covered by healthy granulations.
“In some notes of this case, kindly furnished me by the late Professor
Fergus of King’s College, who had an opportunity of watching the
appearances for some time before the admission of the patient here,
it is mentioned that the flow of blood in the veins was exceedingly
slow, and that hard knotty tumours could be felt in the parts before
they became sphacelated. These swellings all along preceded the
mortification. It is mentioned, besides, that the patient had a sort of
fit, but that it could not exactly be ascertained whether or not she
lost consciousness. Her left arm is said to have been motionless from
and after that time. There is considerable discrepancy in the accounts
of the mode of invasion, and of the duration of the disease, before the
line of separation became apparent. A period of six weeks is stated in
our case-book to have elapsed from the attack to the admission of the
patient into this hospital. It would appear, however, from the other
history, that not more than three weeks had passed over. The old lady
is not very distinct in her account; at one time she makes a statement
with great minuteness, and very soon after contradicts herself on
almost every point. When pressed on the subject, she states that she
got disgusted with her condition, became despondent and careless about
everything, and that her recollection is not now very good.”
“S.W., aged 16, was admitted March 12, under the care of Mr. LISTON.
She is a servant girl, of sanguine temperament and good constitution.
On Friday, March 9, she was cleaning the outside of a parlour window,
and stood on the sill. The window-sash, upon which she was depending
for support, being suddenly drawn down by a person inside, she was
precipitated into an area, a distance of fifteen feet. She was
immediately picked up, and conveyed to the hospital. The house-surgeon
detected a compound fracture of the ulna, and a fracture of the radius,
both fractures being a little above the wrist-joint of the right
arm. The fracture was adjusted, and the wound, which was inferiorly
to, and behind, the wrist, dressed in the usual manner. A dose of
house-medicine was administered; suitable directions were given in
case of the occurrence of pain or swelling; she was sent home, and
desired to remain quiet. The following morning (Saturday) she was
visited by the house-surgeon, who found her comfortable, but she had
passed a sleepless night. On Sunday morning the affected part became so
intolerably painful that she tore off the splints and bandages, which
one of the dressers of the hospital had a short time before readjusted;
in the evening she was in great pain, and the arm was much swollen.
“12. To-day (Monday) she was admitted into the hospital; water-dressing
was applied to the wound. The bandages were reapplied, and an anodyne
administered in the evening, with the effect of producing some rest.
“13. The pain and swelling were so great during the night that the
house-surgeon was called up to see her, and ordered the application of
fomentations; this morning she is much more comfortable.
“14. On removing the whole of the apparatus this morning early,
mortification was found to have taken place in the limb; at the time
of Mr. Liston’s visit in the middle of the day, the limb was very
swollen, the fingers were of a black colour, the forearm livid, there
were vesications near the elbow with fetid discharge. There was a good
deal of fever with slight delirium; pulse irregular, quick. Mr. Liston
considered the only chance the patient had was the immediate amputation
of the limb at the shoulder. The patient’s consent having been readily
obtained, Mr. Liston proceeded at once to the
“_Operation._—He first introduced a long double-pointed knife under
the acromion, and brought the point out at the lower and posterior
border of the axilla, by this means the joint was laid open; the flap
thus formed of a portion of the deltoid was raised, and the head of the
bone separated from its attachments. The other flap was formed from the
integuments and muscles in front. The axillary, and one other vessel,
required ligature. The edges of the wound were drawn together by three
points of suture, and cold water-dressing applied. One grain of muriate
of morphia was given. In the evening, several strips of isinglass
plaster were applied, and the edges approximated. The delirium ceased
after a short but refreshing sleep.
“15. Passed a good night; has had little pain; feels very comfortable
this morning; she is cheerful, and has little fever; pulse 86, regular.
The wound looks healthy.
“April 2. Since the above date, the patient has been gradually
improving in her health and strength, and she is now able to walk about
the ward.”
In gangrene occurring after exposure to cold, amputation should not be
had recourse to till after the line of separation has formed; and in
this case the constitutional symptoms are much less urgent, and the
object of the operation might be frustrated by its being performed in
parts, which would speedily become sphacelated. The amputation may be
performed either at the line of separation by cutting the ligaments
or bones, as was done in the case from which the accompanying sketch
was taken, and when the line of separation is well declared; or,
if by these means a good covering is not likely to be had for the
exposed surface, the incisions may, in these cases, be with safety and
propriety made in the living tissues, at the most convenient point.
[Illustration]