24. In some very rare cases, an intense, deep-seated inflammation
supervenes after some days, almost suddenly and without any obvious
cause. The skin is scarcely affected, although the limb--and this
complaint has hitherto been observed only in the thigh--is swollen, and
exceedingly painful. If relief be not given, these persons die soon,
and the parts beneath the fascia lata appear after death softened,
stuffed, and gorged with blood, indicating the occurrence of an intense
degree of inflammation, only to be overcome by general blood-letting;
and especially by incisions made through the fascia from the wound,
deep into the parts, so as to relieve them by a considerable loss of
blood, and by the removal of any pressure which the fascia might cause
on the swollen parts beneath.
25. Erysipelatous inflammation is marked by a rose or yellowish
redness, tending in bad constitutions to brown or even to purple, but
in all cases terminating by a defined edge on the white surrounding
skin. It frequently spreads with great rapidity, so that the limb,
and even the whole skin of the body, may be in time affected by it,
the redness subsiding and even disappearing in one part, while it
extends in another direction. When this inflammation attacks young
and otherwise healthful persons of apparently good constitution, it
should be treated by emetics, purgatives, and diaphoretics, in the
first instance, with, perhaps, in some cases, bleeding. When the habit
of body is not supposed to be healthy, bleeding is inadmissible, and
stimulating diaphoretics, combined with camphor and ammonia, will be
found more beneficial after emetics and purgatives; these remedies may
in turn be followed by quinine and the mineral acids, with the infusion
and tincture of bark. Little reliance can be placed on large doses of
cinchona in powder; they nauseate and therefore distress.
When the inflammation extends deeper than the skin, into the areolar
or cellular tissue, it partakes more of the nature of the healthy
suppurative inflammation, commonly called phlegmonous, is accompanied
by the formation of matter, and tends to the sloughing or death of this
tissue at an early period. The redness in this case is of a brighter
color, although equally diffuse, and with a determined edge; the limb
is more swollen and tense, and soon becomes quagmiry to the touch. The
skin is then undermined, and soon loses its life, becomes ash colored
and gangrenous in spots, and separates, giving exit to the slough and
matter which now pervade the whole extremity affected. If the patient
survive, it will probably be with the loss of the whole of the skin and
the cellular substance of the limb.
As soon as the inflamed part communicates the springy, fluctuating
sensation approaching, but not yet arrived at the quagmiry feel alluded
to, an incision should be made into it, when the areolæ or cells of
the cellular tissue will be seen of a bright leaden color, and of a
gelatinous appearance, arising from the fluid secreted into them, being
now nearly in the act of being converted into pus. The septa, dividing
the tissue into cells, have not at this period lost their life, and
the fluid hardly exudes, as it will be found to do a few hours later,
when the matter deposited has become purulent. When this change has
taken place, the patient is in danger, and if relief be not given, he
will often sink under the most marked symptoms of irritative fever of
a typhoid type. Nature herself sometimes gives the required relief by
the destruction of the superincumbent skin; but this part is tough,
offers considerable resistance, and does not readily yield until the
deep-seated fascia is implicated, and the muscular parts are about to
be laid bare.
An incision made into the inflamed part through the cellular tissue,
down to the deep-seated fascia, which should not be divided in the
first instance, gives relief. One of four inches in length usually
admits of a separation of its edges to the amount of two inches, by
which the tension of the skin, which principally causes the mischief
which follows the inflammation, is removed. As many incisions are
required as will relieve this tension, according to the extent of the
inflammation, which is also relieved by the flow of blood, but that
requires attention, as it is often considerable, particularly if the
deep fascia be divided on which the larger vessels are found to lie. If
the necessary incisions be delayed until the quagmiry feeling is fully
established, the skin above it is generally undermined and dies. The
following case is given as the first known in London, in which long
incisions were made for the cure of this disease, and their effect in
relieving the constitutional irritation is so strongly marked as to
need no further explanation:--
Thomas Key, aged forty, a hard drinker, was admitted into the
Westminster Hospital, under my care, on the 21st of October, 1823,
having fallen and injured his left arm against a stool, four days
previously. On the 30th, the skin being very tense, the part springy,
and yielding the boggy feel described, pulse 120, mind wandering,
I proposed, in consultation with my colleagues, to make incisions
into the part, but which were considered to be unusual and improper.
On the 31st, the pulse being 140, and everything indicating a fatal
termination, I refrained from any further consultation, although
directed by the rules of the hospital; and, after my old Peninsular
fashion, made an incision eight inches long into the back of the arm,
and another of five on the under edge, in the line of the ulna, down to
the fascia, which was in part divided; one vessel bled freely. The next
day, November 1, the pulse was 90; the man had slept, and said he had
had a good night. The incision on the back of the arm was augmented
to eleven inches; and from that time he gradually recovered, being
snatched as it were from the jaws of death.
This case, published at the time, has been the exemplar on which this
most successful practice has been followed throughout the civilized
world--a practice entirely due to the war in the Peninsula.
When this kind of inflammation attacks the scrotum, which it sometimes,
although rarely, does, as a sporadic disease, independent of any
urinary affection, incisions into it should be made with great caution,
not extending beyond the discolored spots, in consequence of the loss
of blood which would ensue from the great vascularity of the part.
They should be confined to, and not extend beyond, the parts obviously
falling into a state of slough or of mortification.
26. Mortification is the last and most fatal result of inflammation,
although it may occur as a precursor of it in the neighboring parts,
and not as a consequence. The essential distinction is, between that
which is _idiopathic_ or _constitutional_ and that which is _local_;
and has not existed long enough to implicate the system at large, or to
become _constitutional_. Idiopathic or constitutional mortification,
sphacelus or gangrene, may be _humid_ or _dry_. _Humid_, when the death
of the part has been preceded by inflammation and a great deposition
of fluid in it, followed by putrefaction and decomposition, as after
an attack of erysipelas following an injury. It may then be said to
be acute. Dry, when preceded by little or no deposition of fluid in
it, and followed by a drying, shriveling, and hardening of the part,
nearly in its natural form and shape, unless exposed to external causes
usually leading to putrefaction. The most remarkable instances have
occurred in persons suffering from typhus fever, and exposed to cold,
without sufficient covering or care. When it occurs in old persons, or
in those who have lived on diseased rye or other food, it may be called
chronic. The gangrene which follows wounds has been termed _traumatic_,
which explains nothing but the fact of its following an injury.
_Local_ mortification may be the effect of great injury applied direct
to the part, or of an injury to the great vessels of the limb. It may
occur from intense cold freezing the part, or from intense heat burning
or destroying it.
27. It sometimes happens that a cannon-ball strikes a limb, and without
apparently doing much injury to the skin, so completely destroys the
internal textures that gangrene takes place almost without an effort
on the part of nature to prevent it. This kind of injury was formerly
attributed to the wind of a ball; but no one who has seen noses, ears,
etc. injured or carried away, and all parts of the body grazed, without
such mischief following, can believe that either the wind, or the
electricity collected by it, can produce such effect.
The patient is aware of having received a severe blow on the part
affected, which does not show much external sign of injury, the skin
being often apparently unhurt or only grazed; the power of moving the
part is lost, and it is insensible. The bone or bones may or may not
be broken, but in either case the sufferer, if the injury be in the
leg, is incapable of putting it to the ground. After a short time the
limb changes color in the same manner as when severely bruised, and the
necessary changes rapidly go on to gangrene. The limb swells, but not
to any extent, and more from extravasation between the muscles and the
bones than from inflammation, which, although it is attempted to be set
up, never attains to any height. The mortification which ensues tends
to a state between the humid and the dry, and rather more to the latter
than the former. These cases are not of frequent occurrence, and are
not commonly observed until after the blackness of the skin, and the
want of sensibility and motion attract attention; for the patient is
generally stupefied at first by the blow, and the part or parts about
the injury feel benumbed. I made these cases an object of particular
research after the battle of Waterloo, but could find only one among
the British wounded. The man stated that he had received a blow on the
back part of the leg, he believed from a cannon-shot, which brought him
to the ground, and stunned him considerably. On endeavoring to move,
he found himself incapable of stirring, and the sensibility and power
of motion in the limb were lost. The leg gradually changed to a black
color, in which state he was carried to Brussels. When I saw it, the
limb was black, apparently mortified, and cold to the touch; the skin
was not abraded; the leg was not so much swollen as in cases of humid
gangrene; the mortification had extended nearly as high as the knee;
there was no appearance of a line of separation; and the signs of
inflammation were so slight that amputation was performed immediately
above the knee. On dissecting the limb, I found that a considerable
extravasation of bloody fluid had taken place below the calf of the
leg, and in the cavity thus formed some ineffectual attempts at
suppuration had commenced. The periosteum was separated from the tibia
and fibula; the popliteal artery was, on examination, found closed
in the lower part of the ham by coagulated lymph, proceeding from a
rupture of the internal coat of the vessel. Two inches below this the
posterior tibial and fibular arteries were completely torn across, and
gave rise, in all probability, to the extravasation. The operation was
successful. The proper surgical practice in such cases is to amputate
as soon as the extent of the injury can be ascertained, in order
that a joint may not be lost, as the knee was in this instance. It
is hardly necessary to give a caution not to mistake a simple bruise
or ecchymosis for mortification. To prevent such an error leading to
amputation, Baron Larrey has directed an incision to be previously made
into the part, and to this there can be no objection.
When a large shot or other solid substance has injured a limb to
such an extent only as admits of the hope of its being possible to
save it, this hope is sometimes found to be futile, at the end of
three or four days, from a failure of power, in the part below the
injury, to maintain its life for a longer time: mortification is
obviously impending. In military warfare, uncontrollable events often
render amputation unavoidable in such a case. Under more favorable
circumstances, the surgeon should be guided by the principle laid
down of _constitutional_ and _local_ mortification; and, although the
line cannot perhaps be distinctly drawn between them at the end of
three, four, or more days, it will be better to err on the side of
amputation than of delay. If the limb should be swollen or inflamed to
any distance, with some constitutional symptoms, in a doubtful habit of
body, the termination will in general be unfavorable, whichever course
be adopted, more particularly if the amputation must be done above the
knee. The consideration of the circumstances in which the patient is
placed, his age, and habit of body, should have great weight in forming
a decision in the first instance, as to the propriety of attempting
to save the limb, which ought only to be done in persons of good
constitution and apparent strength.
28. Whenever the main artery of a limb is injured by a musket-ball,
mortification of the extremity will frequently be the result,
particularly if it be the femoral artery; it will be of certain
occurrence if both artery and vein are injured, although they may not
be either torn or divided. There may not then be such a sudden loss
of blood, in considerable quantity, as to lead to the suspicion of
the vessel being injured. The fact is known from the patient’s soon
complaining of coldness in the toes and foot, accompanied by pain,
felt especially in the back part or calf of the leg, or in the heel,
or across the instep, together with an alteration of the appearance
of the skin of the toes and instep, which, when once seen, can never
be mistaken. It assumes the color of a _tallow candle_, and soon the
appearance of _mottled soap_. Although there may be little loss of
temperature under ordinary circumstances of comfort, there is a feeling
of numbness, but it is only at a later period that the foot becomes
insensible. This change marks the extent of present mischief. The
temperature of the limb above is somewhat higher than natural, and some
slight indications of inflammatory action may be observed as high as
the ham, and the upper part of the tibia in front; it is at these parts
that the mortification usually stops when it is arrested. The general
state of the patient, during the first three or four days, is but
little affected, and there is not that appearance of countenance which
usually accompanies mortification from constitutional causes. In a day
or two more, the gangrene will frequently extend, when the limb swells,
becomes painful, and more streaked or mottled in color; the swelling
passes the knee, the thigh becomes œdematous, the patient more feverish
and anxious, then delirious, and dies.
An extreme case will best exemplify the practice to be pursued. A
soldier is wounded by a musket-ball at the upper part of the middle
third of the thigh, and on the third day the great toe has become
of a tallowy color and has lost its life. What is to be done? Wait
with the hope that the mortification will not extend. Suppose that
the approaching mortification has not been observed until it has
invaded the instep. What is to be done? Wait, provided there are no
constitutional symptoms; but if they should present themselves, or the
discoloration of the skin should appear to spread, amputation should
be performed forthwith, for such cases rarely escape with life if it
be not done. Where in such a case should the amputation be performed?
I formerly recommended that it should be done at the part injured in
the thigh. I do not now advise it to be done there at an early period,
when the foot only is implicated; but immediately below the knee, at
that part where, if mortification ever stops and the patient survives,
it is usually arrested; for the knee is by this means saved, and the
great danger attendant on an amputation at the upper third of the thigh
is avoided. The upper part of the femoral artery, if divided, rarely
offers a secondary hemorrhage. The lower part, thus deprived by the
amputation of its reflex blood, can scarcely do so; and if it should,
the bleeding may be suppressed by a compress. The blood will be dark
colored. If the upper end should bleed, the blood will be arterial, and
by jets, and the vessel must be secured by ligature.
29. When from some cause or other amputation has not been performed,
and the mortification has stopped below the knee, it is recommended
to amputate above the knee after a line of separation has formed
between the dead and the living parts. This should not be done. The
amputation should be performed in the dead parts, just below the line
of separation, in the most cautious and gentle manner possible, the
mortified parts which remain being allowed to separate by the efforts
of nature. A joint will be saved, and the patient have a much better
chance for life.
30. A wound of the axillary artery rarely leads to mortification of the
fingers or hand. If it should do so, the principle of treatment should
be similar, although the saving of the elbow is not so important as
that of the knee: neither is the amputation in the axilla, below the
tuberosities of the humerus, as dangerous as that above the knee.
31. Mortification after the sudden application of intense cold or heat
is to be treated on similar principles.
32. When a nerve or plexus of nerves conveying sensation and motion,
and going to a part, or an extremity of the body, is divided, the part
or limb is deprived of three great qualities: motion, sensation, and
the power of resisting with effect the application of a degree of heat
or of cold, which is innocuous when applied in a similar manner to the
opposite or sound extremity. In other words, it will be scalded by hot
water and frost-bitten by iced or even cold water, which are harmless
when applied to another and a healthy part.
An officer received, at the battle of Salamanca, two balls, one under
the left clavicle, which was supposed to have divided the brachial
plexus of nerves, as the arm dropped motionless and without sensation
to the side. The other ball passed through the knee-joint, which
suppurated. The left side of the chest became affected; he suffered
from severe cough, followed by hectic fever, and was evidently about
to sink. As a last chance, I amputated his leg above the knee, after
which he slowly recovered. Fourteen years afterward he showed me his
arm in the same state, and told me he had been indicted for a rape, but
that the magistrates, seeing the wooden leg and the useless arm, while
admitting the attempt, would not assent to the committal of the offence.
33. When one nerve only of several going to an extremity such as the
arm and hand, is divided, the loss sustained is confined to the extreme
part more immediately supplied by the injured nerve. Thus, if the ulnar
nerve only be divided, the little finger and the adjacent side of the
ring finger suffer, perhaps in some degree the inner side of the thumb
and the adjoining fingers; if the median nerve, the thumb and other
fingers; if the radial, the back of the hand next the thumb. In some
instances there seems to be a kind of collateral communication by which
a degree of sensibility is after a time recovered.
34. If any foreign substance should lodge in and continue to irritate
the nerve, the wounded part often becomes so extremely painful as not
to be borne; the nerve at that part forms a tumor of a most painful
character, requiring removal, or in extreme cases even the amputation
of the extremity.
35. After an ordinary amputation, the extremity of a nerve enlarges so
as to resemble a leek, and if this should adhere to the cicatrix of
the wound, painful symptoms, referred to the toes and other parts of
the removed leg, are experienced often to an almost unbearable degree;
the end of the nerve should be removed. The pain apparently felt in
and referred to the toes is merely the effect of irritation of the
extremity of the nerve.
36. Wounds or injuries of nerves, which do not entirely divide the
trunk, or a principal branch given off from a plexus of nerves,
may give rise to general as well as to local symptoms; that is, by
sympathy, connection, or continuity of disease, other nerves and organs
of the body are affected. This applies also to the spinal marrow,
when the injury does not destroy at once. General Sir James Kempt was
wounded at the storming of the castle of Badajoz, on the inside of
the left great toe, by a musket-ball which, from the appearance of
a slit-like opening, was supposed to have rebounded from the bone,
but was discovered a fortnight afterward flattened and lying between
it and the next toe. Inflammation had ensued, followed by great
irritability and numerous spasmodic attacks, appearing to render
locked-jaw probable. The spasms soon became general, extending from
the foot to the head, but tetanus did not take place. On his return to
England, they gradually subsided, but he did not sleep at night for a
year. After the battle of Waterloo the spasms became more frequent and
troublesome, attacking the muscles at the back of the neck and throat,
causing considerable anxiety. The attack was often traced to exposing
the foot to cold or to undue pressure, and frequently to derangement
of stomach, although he was most regular in diet. After the lapse of
six or seven years these severe symptoms subsided; but during the last
forty years of his life he suffered occasionally from them.
Admiral Sir Philip Broke received a cut with a sword on boarding the
Chesapeake, on the left side of the back of the head, which went
through his skull, rendering the brain visible; the wound healed in
six months, although splinters of bone came away for a year. A second
cut on the right side did not penetrate the bone. After a temporary
paralysis of the right side, he recovered, with a loss of power and a
disordered sensation in the second, third, and little fingers of the
right hand, aggravated by cold weather and by mental anxiety.
Seven years afterward, he fell from his horse, and suffered from
concussion of the brain, which added to his former sensations by
rendering the left half of his whole person incapable of resisting
cold, or of evolving heat. In a still atmosphere abroad, at 68° Fahr.,
he said, “the left side requires four coatings of stout flannel, which
are augmented as the thermometer descends every two degrees and a half,
to prevent a painful sense of cold; so that when it stands at the
freezing point the quantity of clothing of the affected side becomes
extremely burdensome. When exposed to a breeze, or even in moving
against the air, one or even two oilskin coverings are necessary in
addition, to prevent a sensation of piercing cold driving through the
whole frame. Moderate horse exercise and generous diet improved the
general health; the warm bath caused a distressing effect; the shower
bath, cold or tepid, increased the paralytic affection. Frictions,
with remedies of all kinds, increased it also, and so did sponging
with vinegar and water, as well as any violent, stimulating, quick
excitement, or earnest attention to any particular subject. The Admiral
died unrelieved, twenty-six years after the receipt of the injury, of
disease of the bladder.”
37. Brigade-Major Bissett was wounded on horseback, in the Kaffir war,
by a musket-ball, which entered on the outside of the lower part of
the left thigh, passed upward across the perineum, wounding the rectum
within the anus--from which part he lost a quantity of blood--and
came out through the pelvis on the opposite side. The course of this
ball was accounted for by the fact that he saw the Kaffir who shot
him standing some yards below him when he fired. The ball, in its
passage upward and across the thigh, injured the great sciatic nerve,
and the consequence is continued pain in the toes, instep, and foot,
with contraction of the muscles, and lameness, together with the usual
incapability of bearing heat or cold, particularly the latter, against
which he is peculiarly obliged to guard. The skin shows no sign of
discoloration or derangement. Position gives the explanation why the
ball took such a peculiar course; the symptoms show the nature of the
injury. From other effects he has perfectly recovered, but his leg is
comparatively useless, while it is a constant source of suffering.
38. The cases related in the Lectures on wounds of arteries, of
mortification taking place in the foot and leg, after the division
of the principal artery in the thigh, show that the maintenance of
the life of a part depends on the blood. The cases now related show
that neither an injury nor the division of the principal nerve, nor,
perhaps, of all the nerves going to a part, will destroy that life.
The complete failure of the circulation, in a part such as the foot,
impairs, but does not totally destroy, the sensibility imparted by
the nerves, until after the loss of life has taken place, or until
decomposition is about to occur. An injury then to the nerve causes
great pain, not usually at the part injured, but in the extreme parts
supplied by it; some loss of the power of motion; some deprivation of
its ordinary sensibility, as shown by a feeling of numbness, and an
incapability, to a certain extent, of resisting heat or cold. When all
the nerves have been divided, the power of moving the limb is lost, as
well as its sensibility in a general sense. The temperature remains at
a natural standard under ordinary circumstances, but no extra evolution
of heat can take place by which cold is resisted, nor any absorption
of it, which perhaps renders the application of a high temperature,
particularly when combined with moisture, dangerous. The circulation
is capable of maintaining the ordinary heat of a part, although it is
deprived of the influence of the special nerves of sensation and of
motion; but a greater evolution of heat appears to depend on something
communicated by the nerves in a state of integrity. In the case of Sir
P. Broke, this something appeared to be derived from the brain, on
which part the wound was inflicted, and the transmission of which was
interrupted by the injury. The evolution of animal heat has of late
been supposed to be dependent on electricity, from the resemblance
which exists between it and the nervous power, although the attempts to
identify them have not been successful. That the evolution of heat is
the result of nervous power, appears to be indisputable; in what that
power consists, physiologists have yet to ascertain.
39. The best means of mitigating the pain, independently of the
application of warmth--and cold rarely does good, as the sufferer soon
finds out--is by the application of stimulants to the whole of the
extremity affected, followed by narcotics. The tinctures of iodine and
lytta, the oleum terebinthinæ, the oleum tiglii or cajeputi, the liquor
ammoniæ or veratria, may be used in the form of an embrocation, of such
strength as to cause some irritation on the skin, short, however, of
producing any serious eruption. After the parts have been well rubbed,
opium, belladonna, or henbane may be applied in the form of ointment;
or the tincture of opium, henbane, or aconite may in turn be applied on
linen. Great advantage has been derived in many neuralgic pains from
the application of an ointment of _aconitine_, carefully prepared, in
the proportion of one grain to a drachm of lard, at which strength it
will sometimes irritate almost to vesication, as well as allay pain.
When the pains return from exposure to cold, particularly in the
lower extremity, great advantage has been derived from cupping on the
loins, from purgatives, opiates, and the warm bath. Benefit has been
obtained occasionally from quinine, and from belladonna, aconite, and
stramonium, administered internally in small doses frequently repeated,
but not suffered to accumulate without purgation; as the accumulated
effects are sometimes dangerous.