Elements of Surgery

by Robert Liston

A condition, somewhat resembling sympathetic fever, occasionally supervenes in a constitution that has been suffering from hectic, when any additional irritation occurs, and this fever has been called Irritative. The sanguiferous system becomes more excited—the secretions are suspended—the sensorium is disturbed; but still the symptoms are accompanied with the peculiar debility characterising the state of hectic. It frequently follows the opening of large chronic abscesses by a minute aperture, in the manner formerly described and is relieved only by free evacuation of the confined matter.

In the treatment of hectic, the local disease giving rise to the symptoms, if it cannot be cured by other means, must be removed by operation. Thus, if hectic is consequent on long-continued, but not extensive, disease of bone, the affected portion is to be taken away; if from extensive chronic disease of an arm or leg, the limb must be amputated.

In general, the removal of the hectic cause is followed by immediate melioration of the symptoms, even though the patient has been reduced to an almost moribund condition: the feeble hectic pulse of 120 or 130 sinks in a few hours to 90, and becomes more full and strong; anxiety and restlessness cease, and a patient sleeps soundly the first night after the operation, who for weeks had scarcely closed his eyes; the cold sweats and colliquative diarrhœa immediately subside, and the urine loses its sediment; in effect, all the hectic symptoms disappear, and are succeeded by such as indicate a marked improvement in the power and energy of the constitution; and the rapidity with which these changes take place is in many cases truly astonishing. Nourishing food, wine, tonics, &c., must be given, in the first instance sparingly, and afterwards gradually increased in quantity, according as the stomach can bear them; for it is not to be overlooked, that incautious and too liberal use of them may be productive of irretrievable evils, as the action of the system may be increased beyond its resources, in the same way as the imprudent application of stimulants to a part debilitated by an excessive degree of cold causes its sphacelation, in consequence of the arterial action induced being greater than what the power of the part can support. The mineral acids may be useful in checking the inordinate perspiration; opium, astringents, and absorbents, in arresting the diarrhœa; but all are of little avail unless the exciting cause is removed, and to this latter circumstance the attention of the practitioner ought therefore to be chiefly directed. It is not always quite safe, however, to free the patient at once of a great suppurating drain. Upon the healing up of extensive and long-continued ulcers, it is often necessary, in order to prevent oppression of and congestion in the viscera of the chest, abdomen, or head, to insert an issue or seton, and gradually withdraw it. In amputations also, more especially in patients above the middle period of life, to rid them of disease which has caused hectic and wasting, in consequence of profuse discharge, it is often advisable to keep part of the wound open, so that it may suppurate, heal, and dry up slowly.

Mortification, or the death of a part, is also one of the results of inflammatory action, and the term has been subdivided into Gangrene and Sphacelus. Gangrene is that state in which the larger arterial and nervous trunks still continue to perform their functions; a portion of the natural temperature remains, and the part may be supposed still capable of recovery. Sphacelus, again, expresses complete death, when, putrefaction being no longer resisted, the part becomes black, cold, insensible, and fetid; but, in general, the distinction between the terms is not strictly attended to. A division of more importance is into humid and dry, or traumatic and chronic, gangrene; humid or traumatic being applied to mortification produced by external injury; dry or chronic to that resulting from a constitutional cause.

Mortification is not always a result of inflammation; it is sometimes preceded by incited action of the vessels, sometimes not. It follows as a matter of course that if inflammatory action is so violent as to cause stagnation of blood in most or all the vessels of a part, and this is continued, there must be a consequent failure of nutrition, which will terminate in mortification.

Humid or traumatic gangrene frequently occurs without previous inflammation, the injury being so severe as at once to deprive the part of its vitality. Dry or chronic mortification is often unpreceded by inflammatory action, or at least it is slight and of very short duration. It is preceded by stagnation, or is at all events coincident with this stagnation, not in the smaller vessels only, but in the trunks leading to the affected part. In humid gangrene, swelling with erethismus generally precedes the death of the parts; whereas in the dry, whether the surface change colour immediately or not, they shrink immediately. In the former they quickly lose their vitality, and consequently retain a considerable portion of their fluids; in the latter the process is much slower, and they become dry and shrivelled.

The most common remote cause of spontaneous mortification is a rigid state of the arteries, most frequently met with in the inferior extremities of elderly persons, in consequence of the deposition of calcareous matter between the internal and middle coat; this calcareous degeneration may be confined to a part of the limb, or may pervade the whole of it, and even extend throughout the arterial system. There are many cases in which disease of the arteries has existed, though no gangrene occurred; but this by no means invalidates the assertion, since, when arteries are thus affected, the part cannot withstand sphacelus when exposed to any of its immediate causes. An attempt has been made to connect mortification with an inflamed state of the arterial coats. This opinion is not confirmed by experience. Obstruction from coagulation of their contents, and inflammation of the venous trunks, sometimes precedes death of the extreme parts in old people, and seems to act as a direct cause. After wet seasons, spontaneous gangrene has prevailed as an endemial disease on the Continent, where rye is a principal article of food. The rye is subject to a disease called Ergot; the grains become large, black, and have a horny consistence; and the use of it, when thus diseased, is assigned as the cause of gangrene. The patients who have suffered from the use of this ergot or cockspur rye have experienced pain and heat, with swelling, generally in the lower limbs, though occasionally in the upper. These symptoms abating, the parts became cold, insensible, and discoloured, and were gradually separated from the body. The disease attacked patients of both sexes and every age, did not appear to be infectious, and was frequently fatal. It has occurred in this country from the use of unsound wheat. A tendency to mortification sometimes arises from a peculiar state of the atmosphere, want of cleanliness, poor and irregular diet, &c. Cancrum oris, for example, and sloughing of the pudendum in children, occur in those of the poorer classes who live in low, damp, and dirty situations; and little or no incited action precedes the sloughing. The same may be said of the phagedænic affections of the genital organs. Mortification and ulceration seem to differ merely in this,—in the latter, a part which, from any cause, is unfitted to remain a portion of the living body, is only prevented from dying by absorption just as it is about to lose its vitality; whilst in mortification the part perishes too soon, or in too great quantity, to admit of absorption. Sloughing phagedæna is a sort of connecting link.

Mortification, to a greater or less extent, may be produced in any constitution, and at any age, by the application of heated substances, caustics, acids, &c.; by the effusion of acrid matter into the cellular substances, as urine or putrid sanies; by the interruption of the circulation and nervous energy, as from ligatures or improperly applied bandages—or by natural strictures, as those in hernia and paraphymosis; by continued pressure, more especially in such patients as have, from long suffering and confinement, had the powers of the circulating system weakened; and by violent contusions, as in fractures, compound luxations, and gunshot injuries. A frequent source of mortification, in inclement seasons and climates, is exposure to extreme cold. In this case, the cold is not the direct, but the indirect cause; the power of the parts is very much weakened by exposure to the low temperature, and is thereby rendered incapable of resisting the incited action which follows the stimulus of sudden transition from cold to heat, even though the degree of increase in temperature should not exceed that of the natural standard. That cold is not the direct cause of mortification, has been undeniably proved by facts derived from military practice. No symptoms of inflammation or gangrene occur when the soldier is on duty, and continuously exposed to severe cold; but they speedily present themselves after a rapid thaw has commenced, or after the soldier has imprudently approached a fire. Soon after the half-frozen person has begun to feel a little more comfortable from sudden warmth, he becomes aware of pain, attended with a sensation of itching in the extremities, generally the lower, which are considerably swollen, and of a dull red colour; these, and other symptoms of inflammation, are of no long duration, the action speedily runs its course, and the part soon plainly indicates that gangrene has commenced.

When gangrene follows the tight application of a ligature, the death of the part seems to depend more on obstruction to the circulation of the blood, than on any diminution of the nervous energy, for we do not observe that paralytic limbs are peculiarly liable to gangrene. The surgeon frequently takes advantage of the fact that a part soon dies when its supply of blood is cut off, or its return in the veins interrupted; and has recourse to ligature for removal of parts, When he considers it inexpedient to employ cutting instruments.

Mortification may be produced by the above-mentioned causes, either immediately or consecutively; and it will occur in some constitutions, or states of constitution, at some periods of life, in some structures, and in some parts of the body, more readily than in others.