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.