Elements of Surgery

by Robert Liston

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.