Elements of Surgery. Robert Liston

hopeless cases, more especially of traumatic gangrene, by delirium and coma; in fact, almost all the symptoms of severe constitutional irritation are more or less fully developed. In some cases, the patients are restless and unmanageable; in others, low and dejected. The disease often proceeds with fearful rapidity to a fatal termination, the patient becoming comatose from effusion within the cranium; but in other instances, in which the vigour of the constitution is greater, and the extent of mischief less, the system bears up under the affection, and a separation is effected between the dead and living parts. The danger is in general to be estimated by a consideration of the size and importance of the part, and of the age and constitution. The destructive consequences of sphacelus arise both from a local and general cause; for the mere application of putrid animal substance to a part still alive—the infiltration, for instance, of dark serosity into the cellular tissue in the course of a limb—causes a sort of inflammation attended with symptoms of diminished power, and followed by constitutional disturbance; whilst the ultimate extinction of life may be imputed to the effect produced on the system by the part previously to its becoming sphacelated, and to the sympathy between the system and the parts which are left in a weak and moribund condition, and which seem endowed with a disposition to extend the disease.

      In the treatment of mortification, no one would think of using any means, local or general, so long as the cause remained; and it therefore must in the first place be removed, otherwise the mischief may speedily become irreparable; thus, a stricture must be divided, irritating fluids evacuated, foreign bodies extracted, &c.

      In chronic gangrene the cause is constitutional, and the means employed must be directed accordingly. In general, the power of the constitution requires support, though, in cases where much fever is present, it may often be necessary to keep the patient on low diet: exhibit salines and mild purgatives in the first instance. The effects of food should be attentively watched, and its quantity increased or diminished accordingly. On the subsidence of the fever, and when sphacelus has occurred, wine and animal food must be given abundantly. Stimulants, strictly so called, are not admissible until the line of separation be formed, and their exhibition must then be regulated by the circumstances of the case. Opium and other anodynes are found necessary during the progress of the disease, to allay irritation and produce sleep; opium has been recommended on very high authority, that of Mr. Pott, in mortification of the lower limbs. The bowels must be attended to. Peruvian bark was at one time supposed to be a specific in this disease, but experience has not born out the opinion; it seldom agrees in substance, and the decoction, with or without the compound tincture or sulphate of quina, will be found much more useful in supporting the power and tone of the digestive organs. After the line of separation has been formed, and not till then, the surgeon may interfere, and assist nature in her work, dividing the exposed bones or ligaments by which the dead parts still adhere to the living; or he may perform amputation immediately below the line of demarcation. Amputation in the sound parts cannot be recommended: for vitality is impaired throughout the system, and more particularly near and above the line of demarcation, where, though the structure seems entire, yet the incisions are made in parts really diseased, and which would almost certainly and speedily mortify. In fact, amputation above the line of separation, in whatever way performed, is seldom if ever productive of advantage in spontaneous gangrene.

      In order to prevent the occurrence of gangrene after exposure to intense cold, the frigid part must be cautiously and slowly restored to its natural temperature; first by being either placed in very cold water, or rubbed with snow; afterwards, by the degree of warmth in the applications, and surrounding atmosphere, being gradually increased.

      In acute gangrene, and in robust constitutions, when the affection arises from over-action, abstraction of blood is had recourse to with marked advantage. In some cases it may be employed, but with due caution, even after sphacelus to a slight extent has occurred. In gangrene, purging and bleeding must not be had recourse to but with the greatest circumspection; for it ought always to be remembered, that however strongly they may be indicated, the time is not far distant when they will be totally inadmissible, and when the weakening effects of depletion will prove highly prejudicial, particularly in cases where the mischief is proceeding rapidly.

      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