Elements of Surgery

by Robert Liston

Ulcers are occasionally prevented from healing by the presence of dead portions of tendon, fascia, or cellular tissue, and are accompanied in general with a bad state of constitution; in such it is necessary to clean the surface by a powerful escharotic, and the best is potass. Otherwise, granulations will be produced quickly, it is true, and in abundance, to supply the original substance; but then they are flabby and exuberant, new skin is formed slowly, if at all, and the sore does not contract; but by removing the dead or half-dead surface, a healthy and firm foundation is prepared, on which is securely and gradually raised the new matter for cicatrisation. But caustics are applied injudiciously to firm and healthy granulations which have not yet reached the level of the surrounding parts; they are only useful in repressing exuberant granulations, or in destroying half-dead parts, which interrupt or deteriorate the cure: and when employed, it should be effectually, and once for all.

Along with the topical treatment of ulcers, internal means are, in most cases, indispensable. Thus, in indolent ulcers, the state of the constitution is often sluggish, and ought to be changed by the exhibition of alteratives or stimulants; with this view, much benefit is derived from a prudent and restrained use of mercury, from the lytta vesicatoria, from minute and occasional doses of arsenic, from the free exhibition of sarsaparilla, and from generous diet, porter, and wine. It is however, altogether impossible to lay down fixed rules for the management of sores; every one has some peculiarity in its nature and appearance, every one requires some peculiarity in the applications and mode of dressing, and what may suit well one day will often prove inert or injurious on the succeeding. Again, when any one application or internal remedy is found to agree with the sore, it ought not to be changed for fashion’s sake, from caprice or routine. In this department of surgery, one practitioner excels another, not by his superior knowledge of the various applications, but by his acuteness in selecting the remedy adapted to the particular state of the sore, and in accommodating the various ointments, lotions, or powders, to the different characters which the ulcer assumes during its progress. The healing of sores is very easy in some constitutions, and very difficult in others. Hence, it has been supposed that the long existence of a sore is a salutary process of nature, tending to relieve or prevent some more serious affection, and on this account some are little solicitous to procure its cicatrisation, or at least are careful that the cure shall not be a speedy one. If, indeed, an extensive sore, or a series of sores, be suddenly dried up, the circumstance must be considered as very unfortunate, and the consequences may even be fatal; but such an occurrence is unusual, and the patient may in general be saved by the timely insertion of an issue in the neighbourhood of the sore, or by an active employment of what is best calculated to insure a renewed discharge. Some sores have a disposition to extend by sloughing, and such frequently attack the lips and pudenda of weakly children; they are also met with, amongst the lowest class of prostitutes, in the cleft of the nates, in the groin, &c., and in such cases the sore closely resembles hospital gangrene.

OF HOSPITAL OR CONTAGIOUS GANGRENE, AND SLOUGHING PHAGÆDENA.

This disease has been long known, and has proved very fatal in crowded and badly-aired hospitals. It may break out at any season, but hot, sultry, and damp weather is most favourable to it. No breach of surface, however small, is secure from its attack. The wound becomes painful and swollen, and loses its healthy, florid appearance; the granulations are flabby, and appear as if distended with air; vesicles form, containing serum or a bloody fluid; the pain is stinging; the secretions are suspended; and the wound is either altogether dry, or covered with slimy, tenacious, and peculiarly offensive matter. An ichorous discharge follows, the pain increases. The sore assumes a circular form, and its edges are everted; erysipelas attacks the surrounding integuments, often extending over the whole limb, and forming a principal feature of the disease. In fact, violent erysipelas and hospital gangrene are affections very closely allied to each other, often arising at the same time, and from the same causes. Both are accompanied with great constitutional disturbance; but in erysipelas, this generally precedes, whilst in hospital gangrene, it follows, the appearance of the malady. The lymphatic glands, in the neighbourhood of the gangrenous part, inflame and suppurate, the skin gives way, and the gangrene soon seizes the newly-formed sore. Fever supervenes, the pulse is often full and strong, and the surface hot; there is great nausea and thirst; the tongue is brown, and the bowels much disordered. The inflammation and ichorous discharge increase. A thick slough covers the sore, and its fetor is peculiar and intolerable. The burning pain is excruciating. Blood oozes out, and, in the last stage, the hemorrhage is often copious from large vessels exposed by the ravages of the disease.

Now, extensive mortification occurs, the strength fails, the pulse becomes tremulous and indistinct, the features collapse, the surface is bedewed with a cold sweat, diarrhœa and hiccough come on, and death puts an end to the patient’s suffering. Such is the progress of the disease in those who were previously in perfect health. Often, however, it is attended with typhoid symptoms almost from the beginning, in people whose constitutions are wasted, who have long laboured under disease, or who have been long confined in hospital. The important distinction between these cases must influence the treatment; what succeeds in the one will destroy in the other. It is not the name of the disease which is to be combated, but each symptom as soon as it presents itself.

Those who have been once afflicted with hospital gangrene are extremely liable to its recurrence, and that too on the same sore; though the secondary disease is much less acute. This form has been termed Sloughing Phagædena, and may seize a sore not previously affected with gangrene. The wound, recovering from the first attack, and appearing to heal rapidly, with good discharge and healthy surface, presents, near its edge, a small dark spot or ulceration, of the size of a small bead or shot, of a circular form, with a ragged edge, excavated surface, and fetid discharge. Several such points may appear; they spread rapidly, unite, and the surface is soon destroyed. It is not uncommon to find one part of the sore of a healthy appearance, and even cicatrising, whilst in another part the surface is rapidly disappearing. The patient complains of a burning sensation in the part; suppuration occurs round the edges and beneath the slough, and the dead parts separate; but the same process again takes place, and another slough forms. The malady proceeds often with a rapid and alarming pace; the sloughs are soft, pulpy, and reddish, and separate one after another, exposing muscles, nerves, bloodvessels, and bones. Joints are opened into, and the vessels, having been exposed, perhaps for a day or two, give way, and fatal hemorrhage ensues, their cavities not being obstructed with coagula as in sphacelus. The patient is sick, has no appetite, and labours under other symptoms of deranged stomach; there is restlessness, with a small quick pulse, and all the symptoms of a weakened and sinking system. The ulceration becomes more rapid, the discharge is bloody and peculiarly offensive; all the symptoms increase in violence, and may proceed for fifteen or twenty days, or terminate in four or five, either in convalescence or death.

Hospital gangrene is supposed to arise from a variety of causes: from the state of the atmosphere, moist and hot—from inattention to cleanliness, the parts around the sore being seldom wiped, the matter collecting amongst the dressings, and becoming acrid by putrescence—from irritating applications, as rancid ointments—from a too stimulating diet, and from the abuse of wine and spirits—from mechanical irritation, in moving the wounded over rough roads and in bad conveyances, as after great engagements—from specific contagion without immediate contact. After being once generated, it is propagated by direct communication, by the application of morbific matter from sponges, dressings, or instruments. It is not easy to say how the disease originates.

In the treatment of this scourge, great attention must be paid to cleanliness in all circumstances. Free ventilation must be constantly preserved in the apartments of the sick, and fumigations assiduously employed. The infected ought to be separated from the others, and but few patients placed in the same ward. Stagnant drains and accumulations of filth out of doors are to be removed; otherwise, during hot weather, the atmosphere becomes much vitiated. Care must be taken, also, to destroy all the dressings which have been used; not to employ sponges, but to wipe the surface in the neighbourhood of the sore occasionally with tow, which is to be burnt immediately, being an article of little value, and easily procured. Too much attention cannot be paid to the cleaning of those instruments with which gangrenous sores have been treated, before they be applied to healthy wounds. As to the constitutional treatment, the alimentary canal must first be purged of its solid contents, and the secretions afterwards kept in as good a condition as possible. When the wound or sore is surrounded with intense inflammation, and when the skin is dry and the pulse strong and full, with all the other symptoms of an inflammatory diathesis, immediate recourse must be had to free abstraction of blood from the system, as thus only can the progress of the disease be efficiently arrested; and if inflammatory symptoms exist, when there is reason to expect the occurrence of the disease, though no symptom of it has yet appeared, then, too, venesection combined with purgatives is demanded, as being the most powerful preventives. Emetics are also recommended. When the affection is from its commencement accompanied with typhoid symptoms, depleting measures must do irreparable mischief: in such cases, the local pain and irritation will be relieved by the exhibition of opium or camphor, and it may also be of service to preserve a perspirable state of the surface by means of Dover’s powder, or other diaphoretics. Preparations of Peruvian bark, the decoction with or without the tincture and acid, or the sulphate of quina, are often given with great advantage—opium is also usefully exhibited. Vinegar, weak acids, the nitric and muriatic acids diluted, have been used as external applications, and nitrate of silver, the red oxide of mercury, and the actual cautery, have been applied with the view of removing the diseased parts, and procuring a healthy surface. Arsenic in solution, used so as to produce a slough, followed by hot dressings, has been supposed to be serviceable. A much safer and more powerful application is the strong nitric acid, which sometimes requires to be applied over the diseased surface very freely, and repeated if need be.

THE MALIGNANT PUSTULE

Is a gangrenous inflammation of the skin, rarely extending to the subcutaneous cellular tissue, and in this respect differs from carbuncle, which commences and is seated in the cellular texture. It arises from the application of the fluids of animals which have died of putrid diseases common in some marshy and low situations. It is communicated not only by matter from the diseased part, but also by the blood of the animal; thus it is frequently observed in those who handle the recent skin or flesh; and the excrements also appear to be possessed of the poisonous principle. It spreads from one person to another by contact. There is much reason to doubt, whether carrion introduced into the stomach produces this disease, though by some it is maintained that even the respiration of effluvia from putrescent substances produces malignant fever, with fetid evacuations and gangrenous patches on the skin. In the West of Scotland, an instance occurred some years ago, in which several persons lost their lives from eating the flesh of dead animals which had been washed ashore. The occurrence of malignant pustule is rare in this country. Some time since, I met with a well-marked case in a shoemaker, who had been employed in killing some sickly pigs. Whilst turning over and removing the abdominal viscera of one of them, he had scratched his finger slightly with a pin stuck in his jacket, and he then perceived that the contact of some putrid matter from the intestines caused great pain. On the third or fourth day afterwards, he presented himself with a malignant pustule formed on the hand between the fore and middle fingers. The pain was very intense, and the disease seemed to be fast extending. Active treatment was employed, and the patient had a speedy recovery.