Elements of Surgery. Robert Liston

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.

      Inflammatory action is seldom so intense as to terminate in death of the part, unless the power of that part has been diminished by previous local or constitutional disease, or by injury; and the inflammation preceding gangrene is all along attended by symptoms of so well-marked debility, both local and general, that it is frequently designated the Inflammatio Debilis. Of inflammatory affections, the erysipelatous most frequently terminates in gangrene; in other words, the power of resisting incited action is not so great in the cellular tissue and skin as in other parts of the body.

      The period at which the symptoms of gangrene appear after an accident varies, in general, according to the severity of the injury. As was already observed, the part may be immediately deprived of its vitality—if not, symptoms of gangrene sometimes appear within a few hours after reaction has taken place; while in other cases, tension, pain, and heat occur, and may continue for a longer or shorter time, according to the degree of power remaining in the part. Tension often exists to a great extent after severe injuries, from extravasation of blood or serum; the functions of the vessels are thereby interrupted, and gangrene is inevitable. As the action proceeds, the pain and heat often subside—the parts become flaccid—dark-coloured serum is effused beneath the cuticle, forming what are termed Phlyctenæ—the skin becomes dull and livid—dark streaks extend along the limb, perhaps from the colouring matter of the blood transuding, as in commencing putrefaction in the dead body—air is effused into the subcutaneous cellular tissue, causing a sense of crepitation when pressed by the finger—sloughs form, either black or of an ash colour—and the gangrene involves a greater or less extent of the limb. The mortification is here represented as attacking a limb that had suffered from compound fracture. The dark part around and above the protruded bone was in a state of sphacelus. The dorsum of the foot and the integument towards the knee were only gangrenous. The patient was advanced in life, and the state of the constitution such as to induce a belief that there was a predisposition to mortification. The removal of the limb was, under the circumstances, reckoned inexpedient. In some instances, the mortification is most towards the surface; in others, it is chiefly amongst the deeply seated parts. Sudden cessation of pain is generally regarded as an unequivocal sign of the occurrence of gangrene, especially in the internal viscera; but it not unfrequently happens that the painful sensations suddenly cease, whilst no gangrene supervenes, and that a part mortifies, whilst the pain continues but little abated.

      In compound fractures, dislocations, or severe bruises of the soft parts, dark-coloured, prominent points occasionally appear, in consequence of the effusion of bloody serum beneath the cuticle; in these, however, the fluid is speedily absorbed, and the surface resumes its natural aspect, the cuticle exfoliating and being reproduced; and it is of consequence to know their real nature, for, if mistaken for the gangrenous phlyctenæ, the inexperienced practitioner may be alarmed, and, consequently, have recourse to very injudicious practice.

      When the process of gangrene is checked, the skin immediately beyond the mortified part becomes of a brighter hue, and is affected by a more healthy species of inflammation, which ultimately terminates in ulceration, with purulent discharge, and thereby forms what is called the line of demarcation between the dead and the living parts; the process, commencing in the integuments, gradually extends to the deeply seated parts, so that the mortified portion is ultimately attached to the living merely through the medium of bone or ligament. Arteries appear more than any other texture to resist sloughing; and those leading to a mortified part are found contracted and filled with coagulated blood, so that the spontaneous separation of the sloughs, and even incisions for their removal, made in sound parts, are followed by little or no bleeding. This salutary change in the arteries may be accounted for by supposing, that the inflammatory action which leads to the separation of the dead substance from the living affects the arteries at that point as well as the other structures, causing adhesion of their internal surface, and obliteration of their cavities; and the natural result is, that the calibre of the artery above the obliterated point gradually diminishes in size, and the blood coagulates up to the nearest collateral branch: but in consequence of extension of the inflammatory action, the collateral branches may also be obliterated to a considerable extent upwards, and thus the contraction and coagulation in the larger trunk will also extend in proportion. Besides, before the line of separation has commenced, arteries cannot transmit their contents into the sphacelated part, any more than into an extraneous body; so that the circulation of the blood in them is as effectually obstructed as if a ligature were tightly applied; in this way, also, the contraction and coagulation may be accounted for.

      Mortification is accompanied with great anxiety; coldness and clamminess of the face and extremities; weak, irregular, and hurried circulation; quick, short breathing; a cadaverous expression of countenance; hiccup (which, however, often occurs in very slight sloughing, or when no sloughing has taken place, in external or internal inflammations, extravasations, &c.); by diarrhœa, vomiting,