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Lectures ON SOME OF THE MORE IMPORTANT POINTS IN SURGERY.
MARCH 6, Lectures ON
SOME OF THE MORE IMPORTANT POINTS IN SURGERY. BY G. J.
GUTHRIE, ESQ.,
F.R.S.
LATE PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND; CONSULTING-SURGEON TO THE WESTMINSTER HOSPITAL, SURGEON TO THE ROYAL WESTMINSTER OPHTHALMIC HOSPITAL, ETC.
LECTURE III. 24. IN some very rare cases, an intense deep-seated inflammation supervenes after some days, almost suddenly, and without any obvious cause. The skin is scarcely affected, although the limb,-and this complaint has hitherto been observed only in the thigh,-is swollen, and exceedingly painful. If relief is not given, these persons die soon, and the parts beneath the fascia lata appear after death softened, stuffed, and gorged with blood, indicating the occurrence of an intense degree of inflammation, only to be overcome by general bloodletting, even to syncope; and by incisions made through the fascia from the wound, deep into the parts, so as to relieve them by a considerable loss of blood; and by the removal of any pressure which the fascia might cause on the swollen parts beneath. 25. Erysipelatous inflammation is marked by a rose or yellowish redness, tending in bad constitutions, to brown, or even to purple, in all cases terminating by a defined edge on the white surrounding skin. It frequently spreads with great rapidity, so that the limb, and even the whole skin of the body, may be in time affected by it; the redness subsiding, and even disappearing in one part, whilst it extends in another direction. When this inflammation attacks young and otherwise healthful persons of apparently good constitutions, it should be treated by emetics, purgatives, and diaphoretics, in the first instance, with perhaps, in some cases, bleeding. When the habit of body is not supposed to be healthy, bleeding is inadmissible ; and stimulating diaphoretics, combined with camphor and ammonia, will be found more beneficial after emetics and purgatives; and these remedies may in turn be followed by quinine and the mineral acids, with the infusion and tincture of bark. Little reliance can be placed on large doses of cinchona in powder, which nauseate and therefore distress. When the inflammation extends deeper than the skin, into the areolar or cellular tissue, it partakes more of the nature of the healthy suppurative inflammation commonly called phlegmonous, is accompanied by the formation of matter, and tends to the sloughing or death of this tissue at an early period. The redness, in this case, is of a brighter colour, although equally diffuse, and with a determined edge; the limb is more swollen, tense, and soon becomes quagmiry to the touch. The skin is then undermined, and soon loses its life, becomes gangrenous in spots, and separates, giving exit to the slough and matter, which now pervade the whole extremity affected. If the patient survive, it is probably with the loss of the whole of the skin and cellular substance of the limb. As soon as the inflamed part communicates the springy fluctuating sensation approaching to, but not having arrived at the quagmiry feel alluded to, an incision should be made into it, when the areolse or cells of the cellular tissue will be seen of a light leaden colour, and of a gelatinous appearance arising from the fluid secreted into them now nearly in the act of being converted into pus. The septa dividing the tissue into cells have not, at this period, lost their life, and the fluid hardly exudes, as it will be found to do a few hours later, when the matter deposited has beWhen this change has taken place, the come purulent. patient is in danger, and if relief be not given, he will often die under the most marked symptoms of irritative fever of a typhoid type. Nature herself sometimes gives the required relief, by the destruction of the superincumbent skin; but this part is tough, offers considerable resistance, and does not readily yield until the deep-seated fascia is implicated, and the muscular parts are about to be laid bare,
No. 1488.
II ’,
’, ’,
1852.
An incision made into the inflamed part, through the cellular tissue, and down to the deeper-seated fascia, which should not be divided in the first instance, gives relief. One of four inches in length usually admits of a separation of its edges to the amount of two inches, by which the tension of the skin, which principally causes the mischief which follows the inflammation, is removed. As many incisions are required as will relieve this tension, according to the extent of the inflammation, which is also relieved by the flow of blood, which requires attention, as it is often considerable, particularly if the deep fascia be divided, on which the larger vessels are found to lie. If the necessary incisions are delayed until the quagmire feeling is fully established, the skin above it is generally undermined and dies. The following case is given as the first known in London in which long incisions were made for the cure of this disease; and their effect in relieving the constitutional irritation is so strongly marked as to need no further explanation. Thomas K-, aged forty, a hard drinker, was admitted into the Westminster Hospital, under my care, on the 21st of October, 1823, having fallen and injured his left arm against a stool four days previously. On the 30th, the skin being very tense, the part springy and yielding the boggy feel described, pulse 120, mind wandering, I proposed, in consultation with my colleagues, to make incisions into the part; but which were considered to be unusual and improper. On the 31st, the pulse being 130, and everything indicating a fatal termination, I refrained from any further consultation, although directed by the rules of the hospital; and, after my old Peninsular fashion, made an incision eight inches long into the back of the arm; and another of five, on the under edge, in the line of the ulna, down to the fascia, which was in part divided; and one vessel bled freely. The next day, Nov. 1, the pulse was 90 ; the man had slept, and said he had had a good night. The incision on the back of the arm was augmented to eleven inches; and from this time he gradually recovered. This case has been the exemplar on which this most successful practice has been followed throughout the civilized world. When this kind of inflammation attacks the scrotum, which it sometimes although rarely does, as a sporadic disease, and independent of any urinary affection; incisions into it should be made with great caution and of small extent, in consequence of the loss of blood which will ensue from the great vascularity of the part. They should be confined to, and not extend beyond, the parts obviously falling into a state of slough or of mortification. 26. Mortification is the last and most fatal result of inflammation, although it may occur as a precursor of it in the neighbouring parts, and not as a consequence. The essential distinction is, between that which is idiopathic or constitutional and that which is local, and has not existed long enough to implicate the system at large, or to become constitutional. Idiopathic or constitutional mortification, sphacelus or gangrene, may be humid or dry. Humid when the death of the part has been preceded by inflammation and a great deposition of fluid in it, followed by putrefaction and decomposition, as after an attack of erysipelas following an injury. It may then be said to be acute. Dry when preceded by little or no deposition of fluid in it, and followed by a drying, shrivelling, and hardening of the part, nearly in its natural form and shape, unless exposed to external causes usually leading to putrefaction. This, when it occurs in old persons, or in those who have lived on diseased rye or other food, may be called chronic. The gangrene which follows wounds has been termed traumatic, which explains nothing but the fact of its following an
injury.
Local mortification may be the effect of great injury applied direct to the part, or of an injury to the great vessels of the limb. It may occur from intense cold freezing the part, or from intense heat burning or destroying it. 27. It sometimes happens that a cannon-ball strikes a limb, and without apparently doing much injury to the skin, so completely destroys the internal textures, that gangrene takes place almost without an effort on the part of nature to prevent it. This kind of injury was formerly attributed to the wind of a ball; but no one who has seen noses, ears, &c., injured or carried away, and all parts of the body grazed, without such mischief following, can believe that either the wind, or the collected by it can produce such effect. electricity The patient is sensible of having received a severe blow on the part affected, which does not show much external sign of L
234 the skin being often apparently unhurt only grazed; injury, themotion of the part is lost, and is insensible; the bone the bones but in either be or
it
or
case broken, may or may not sufferer, injury be in the leg, is incapable of putting it to the ground. After a short time the limb changes colour in the same manner as when severely bruised, and the necessary changes rapidly go on to gangrene. The limb swells, but not to any extent, and more from extravasation between the muscles and the bones than from inflammation, which, although it is attempted to be set up, never attains to any height. The mortification which ensues tends to a state between the humid and the dry, and rather more to the latter than the former. These cases are not of frequent occurrence, and are not commonly observed until after the blackness of the skin, and the want of sensibility and motion, attract attention; for the patient is generally stupified at first by the blow, and the part or parts about the injury feel benumbed. I made these cases an object of particular research after the battle of Waterloo, but could find only one among the British wounded. The man stated that he had received a blow on the back part of the leg, he believed from a cannon-shot, which brought him to the ground, and stunned him considerably. On endeavouring to move, he found himself incapable of stirring, and the sensibility and power of motion in the limb were lost. The leg gradually changed to a black colour, in which state he was carried to Brussels. When I saw it, the limb was black, apparently mortified, and cold to the touch; the skin was not abraded; the leg was not so much swollen as in cases of humid gangrene; the mortification had extended nearly as high as the knee; there was no appearance of a line of separation; and the appearances of inflammation were so slight, that amputation was performed immediately above the knee. On dissecting the limb, I found that a considerable extravasation of bloody fluid had taken place below the calf of the leg, and in the cavity thus formed some ineffectual attempts at suppuration had commenced. The periosteum was separated from the tibia and fibula; the popliteal artery was, on examination, found closed in the lower part of the ham by coagulated lymph, proceeding from a rupture of the internal coat of the vessel. Two inches below this the posterior tibial and fibular arteries were completely torn across, and gave rise, in all probability, to the extravasation. The operation was successful. The proper surgical practice in such cases is to amputate as soon as the extent of the injury can be ascertained, in order that a joint may not be lost. It is hardly necessary to give a caution not to mistake a simple bruise or ecchymosis for mortification. To prevent such an error leading to amputation, the Baron Larrey has directed an incision to be previously made into the part, and to this
if the
there can be no objection, 27. When a large shot or other solid substance has injured a limb to such an extent only as admits of the hope of its being possible to save it, this hope is sometimes found to be futile, at the end of three or four days, from a failure of power in the part below the injury to maintain its life for a longer time: mortification is obviously impending. In military warfare, uncontrollable events often render amputation unavoidable in such a case. Under more favourable circumstances, the surgeon should be guided by the principle laid down of constitutional and local mortification; and although the line cannot perhaps be distinctly drawn between them at the end of three, four, or more days, it will be better to err on the side of amputation than of delay. If the limb should be swollen or inflamed to any distance, with some constitutional symptoms, in a doubtful habit of body, the termination will in general be unfavourable, whichever course be adopted, more particularly if the amputation must be done above the knee. The consideration of the circumstances in which the patient is placed, his age, and his habit of body, should have great weight in forming a decision, in the first instance, as to the propriety of
attempting to save the limb.
28. Whenever the main artery of a limb is injured by a musket-ball, mortification of the extremity will frequently be the result, particularly if it be the femoral artery; and it will be of certain occurrence if both artery and vein are injured, although they may not be either torn or divided. There may not then, be such a sudden loss of blood, in considerable quantity, as to lead to the suspicion of the vessel being injured. The fact is known from the patient’s soon complaining of coldness in the toes and foot, accompanied by pain, felt especially in the back part or calf of the leg, together with an alteration of the appearance of the skin of the toes and instep, which, when once seen, can never be mistaken. It assumes
the colour of
a
tallow candle, and
soon
of mottled soap;
although there may be little loss of temperature under ordi-
nary circumstances of comfort, there is a feeling of numbness, but it is only at a later period that the foot becomes insensible. This change marks the extent of present mischief. The temperature of the limb above is somewhat higher than natural, and some slight indications of inflammatory action may be observed as high as theham, and the upper part of the tibia in front; and it is at these parts that the mortification usually stops when it is arrested. The general state of the patient, during the first three or four days, is but little affected, and there is not that appearance of countenance which usually
accompanies mortification from constitutional causes. In a day or two more, the gangrene will frequently extend, when the limb swells, becomes painful, and more streaked or mottled in colour; the swelling passes the knee, the patient becomes feverish, anxious, delirious, and dies. An extreme case will best exemplify the practice to be pursued. A soldier is wounded by a musket-ball at the upper part of the middle third of the thigh, and on the third day
the great toe is clearly gangrenous. What is to be done1 Wait with the hope that the mortification will not extend. Suppose that the approaching mortification has not been observed until it has invaded the instep. What is to be done? Wait, provided there are no constitutional symptoms; but if they should present themselves, or the discoloration of the skin should spread, amputation should be performed forthwith, for such cases rarely escape with life. Where in such a case should the amputation be performed? I formerly recommended that it should be done at the part injured in the thigh. I do not now advise it to be done there at an early period, when the foot only is implicated, but immediately below the knee, at that part where, if mortification ever stops and the patient survives, it is usually arrested; for the knee is by this means saved, and the great danger attendant on an amputation at the upper third of the thigh is avoided. The upper part of the femoral artery, if divided, rarely offers a secondary haemorrhage. The lower part, thus deprived by the amputation of its reflex blood, can scarcely do so; and if it should, thebleeding may be suppressed by a compress. The blood will be dark-coloured. If the upper end should bleed, the blood will be arterial, and by jets, and the vessel must be secured by ligature. 29. When from some cause or other amputation has not been performed, and the mortification has stopped below the knee, it is recommended to amputate above the knee after a line of separation has formed between the dead and the living parts. This should not be done. The amputation should be performed in the dead parts, just below the line of separation, in the most cautious and gentle manner possible; the mortified parts which remain being allowed to separate by the efforts of nature, a joint will be saved, and the patient have a much better chance for life. 30. A wound of the axillary artery rarely leads to mortifica. tion of the fingers or hand. If it should do so, the principle of treatment should be similar, although the saving of the elbow is not so important as that of the knee; neither is the amputation in the axilla, below the tuberosities of the humerus, as dangerous as that above the knee. 31. Mortification, after the sudden application of intense cold or heat, is to be treated on similar principles. 32. When a nerve, or plexus of nerves, conveying sensation and motion, and going to a part or an extremity of the body, is divided, the part or limb is deprived of three great qualitiesmotion, sensation, and the power of resisting with effect the application of a degree of heat or of cold which is innocuous when applied in a similar manner to the opposite or sound extremity. In other words, it will be scalded by hot water and frost-bitten by iced water, which are harmless when applied to another and a healthy part. An officer received, at the battle of Salamanca, two balls, one underneath the left clavicle, which was supposed to have divided the brachial plexus of nerves, as the arm dropped motionless and without sensation to the side. The other ball passed through the knee-joint, which suppurated. The left side of the chest became affected; he suffered from severe cough, followed by hectic fever, and was evidently about to sink. As a last chance, I amputated his leg above the knee, after which he slowly recovered. Fourteen years afterwards, he showed me his arm in the same state, and told me he had been indicted for a rape, but that the magistrates, seeing the wooden leg and the useless arm, in admitting the attempt, would not assent to the committal of that offence. 33. When one nerve only of several going to an extremity, such as the arm and hand, is divided, the loss sustained is confined to the part more immediately supplied by the’ injured nerve. Thus, if the ulnar nerve only is divided, the little
235 and the
muscles, Ithe he
and lameness, together with the usual incapability or cold, particularly the latter, against which is peculiarly obliged to guard. The skin shows no sign of discoloration or derangement. Position gives the explanation why the ball took such a peculiar course; the symptoms show the nature of the injury. From other effects he has sensibility is after a time recovered. 34. If any foreign substance should lodge in, and continue to perfectly recovered, but his leg is comparatively as useless to as an artificial one, whilst it is a constant source of irritate the nerve, the wounded part often becomes so extremely misery. painful as not to be borne. The nerve at that part forms a suffering, sometimes aggravated to that ofmortification 38. The cases related elsewhere, of tumour of a most painful character, requiring removal, or in taking extreme cases even the amputation of the extremity. place in the foot and leg, after the division of the principal 35. After an ordinary amputation, the extremity of a nerve artery in the thigh, show that the maintenance of the life of a enlarges so as to resemble a leek, and if this should adhere to part depends on the blood. The cases now related show that the cicatrix of the wound, painful symptoms, referred to the neither an injury nor the division of the principal nerve, nor, toes and other parts of the removed leg, are experienced often perhaps, all the nerves going to a part, will destroy that life. to an almost unbearable degree, when it must be treated in a The complete failure of the circulation in a part such as the similar manner to obtain relief. The pain apparently felt in impairs, but does not totally destroy, the sensibility imand referred to the toes is merely the effect of irritation of parted by the nerves, until some hours-nay, days-after the the extremity of the nerve. of life has taken place, nor until decomposition is about 36. Wounds or injuries of nerves, which do not entirely to occur. An injury then to the nerve causes great pain in divide the trunk or a principal branch given off from a plexus parts supplied by it; some loss of the power of motion, of nerves, may give rise to general as well as local symptoms- some deprivation of its ordinary sensibility, as shown by a that is, by sympathy, connexion, or continuity of disease, feeling of numbness; and an incapability, to a certain extent, other nerves and organs of the body are affected. This applies of resisting heat or cold. When all the nerves are divided, the also to the spinal marrow, when the injury does not destroy at power of moving the limb is lost, as well as its sensibility in once. General Sir James Kempt was wounded at the storming a general sense. The temperature remains at a natural of the castle of Badajos, on the inside of the left great toe, by a standard under ordinary circumstances, but no extra evolution musket-ball, which from the appearance of a slit-like opening of heat can take place by which cold is resisted, nor any was supposed to have rebounded from the bone, but was disabsorption of it which perhaps renders the application of a covered a fortnight afterwards, flattened and lying between this high temperature, particularly when combined with moisture, and the next toe. Inflammation had ensued, followed by great The circulation is capable of maintaining the irritability and numerous spasmodic attacks, appearing to render ordinary heat of a part although it is deprived of the inlocked-jaw probable. The spasms soon became more general, fluence of the special nerves of sensation and of motion, extending from the foot to the head, but tetanus did not take but a greater evolution of heat appears to depend on someplace; on his return to England, they gradually subsided, thing communicated by the nerves in a state of integrity. but he did not sleep at night for a year. After the battle of In the case of Sir P. Broke, this something appeared to be Waterloo the spasms became more frequent and troublesome, derived from the brain, on which part the wound was inflicted, attacking the muscles at the back of the neck and throat, and the transmission of which was interrupted by the injury. causing considerable anxiety. The attack was often traced The evolution of animal heat has of late been supposed to be to exposing the foot to cold or to undue pressure, and fre- dependent on electricity, from the resemblance which exists quently to derangement of stomach, although he was most between it and the nervous power, although the attempts to regular in diet. After the lapse of six or seven years these identify them have not been successful. That the evolution severe symptoms subsided, but he now, at the end of forty of heat is the result of nervous power, appears to be indisyears, suffers occasionally from them. putable ; in what that power consists, physiologists have yet Admiral Sir Philip Broke received a cut with a sword on to ascertain. 39. The best means of mitigating the pain, independently of boarding the Chesapeake, on the left side of the back of the head, which went through his skull, rendering the brain visible, the application of heat-and cold rarely does good, which the which wound healed in six months, although splinters of bone sufferer soon finds out-is by the application of stimulants to came away for a year. A second cut on the right side did not the whole of the extremity affected, followed bv narcotics. penetrate the bone. After a temporary paralysis of the right The tinctures of iodine and lyttse, the oleum terebinthae, the side, he recovered with a loss of power and a disordered sen- oleum tiglii, the liquor ammonise or the veratria, in the form of sation in the second, third, and little fingers of the right hand, an embrocation, of such strength as will cause a good deal of irritation on the skin, short, however, of producing any aggravated by cold weather and by mental anxiety. Seven years afterwards he fell from his horse and suffered serious eruption. After the parts have been well rubbed, from concussion of the brain, which added to his former sen- opium, belladonna, or henbane should be applied in the form sations, by rendering the left half of his whole person incapable of ointment; or the tinctures of opium, henbane, or aconite of resisting cold, or of evolving heat. In a still atmosphere may in turn be applied on linen. Great advantage has been abroad, at 68° Fahr., he said, the left side requires four coatings derived in many neuralgic pains from the application of aconiof stout flannel, which are augmented as the thermometer tine carefully prepared, in the proportion of one grain to a descends every two degrees and a half, to prevent a painful drachm of lard, at which strength it will sometimes irritate sense of cold; so that when it stands at the freezing point the almost to vesication, as well as allay pain. When the pains return from exposure to cold, particularly quantity of clothing on the affected side becomes extremely burdensome. When exposed to a breeze, or even in moving in the lower extremity, great advantage has been against the air, one or even two oilskin coverings are necessary from cupping on the loins, from purgatives, opiates, and the in addition, to prevent a sensation of piercing cold driving warm bath. Benefit has been obtained occasionally from quinine, belladonna, aconite, and stramomium, administered through the whole -frame. Moderate horse exercise and generous diet improved the internally. general health; the warm-bath caused a distressed effect; the shower-bath, cold or tepid, increased the paralytic affection. Frictions with remedies of all kinds increased it also, and so did ON A CASE OF CONGENITAL STRANGULATED INGUINAL HERNIA. sponging with vinegar-and-water, as well as any violent stimulating quick excitement, or earnest attention to any particular ARTIFICIAL ANUS; DEATH: WITH REMARKS. OPERATION; subject. The admiral died unrelieved, twenty-six years after BY HENRY BULLOCK, ESQ., the receipt of the injury, of disease of the bladder. RESIDENT SURGEON TO ST. MARY’S HOSPITAL. 37. Brigade-Major Bissett was wounded, on horseback, in the Kaffir war, by a musket-ball, which entered on the J. S-, aged thirty-eight, married, a tobacco-pipe maker, outside of the lower part of the left thigh, passed upwards across the perinseum, wounding the rectum within the anus- was admitted into St. Mary’s Hospital, under Mr. Coulson, at from which part he lost a quantity of blood-and came out ten A.M. on the 6th November, 1851. He stated that ever since through the pelvis on the opposite side. The course of a boy he had had a rupture in the right groin, which had this ball was accounted for by the fact that he saw the always been reducible. He had worn a truss, which he was Kaffir who shot him standing some yards below him when he in the habit of leaving off during the night, up to about ten fired. The ball, in its passage upwards and across the thigh, days ago, when, owing to the spring having broken, he left it injured the great sciatic nerve, and the consequence is con- off for about two hours, during which time he was walking tinued pain in the toes, instep, and foot, with contraction of about; soon after this he complained of pain in the groin
adjacent side of the ring-finger suffer, perhaps degree the inner side of the thumb; if the median nerve, the thumb and other fingers; if the radial, the back of the hand, next the thumb. In some instances there seems to be a kind of collateral communication, by which a degree of
finger
in
some
of bearing heat
him
foot, loss
the
harmless.
derived
___
SOME OF THE MORE IMPORTANT POINTS IN SURGERY. BY G. J.
GUTHRIE, ESQ.,
F.R.S.
LATE PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND; CONSULTING-SURGEON TO THE WESTMINSTER HOSPITAL, SURGEON TO THE ROYAL WESTMINSTER OPHTHALMIC HOSPITAL, ETC.
LECTURE III. 24. IN some very rare cases, an intense deep-seated inflammation supervenes after some days, almost suddenly, and without any obvious cause. The skin is scarcely affected, although the limb,-and this complaint has hitherto been observed only in the thigh,-is swollen, and exceedingly painful. If relief is not given, these persons die soon, and the parts beneath the fascia lata appear after death softened, stuffed, and gorged with blood, indicating the occurrence of an intense degree of inflammation, only to be overcome by general bloodletting, even to syncope; and by incisions made through the fascia from the wound, deep into the parts, so as to relieve them by a considerable loss of blood; and by the removal of any pressure which the fascia might cause on the swollen parts beneath. 25. Erysipelatous inflammation is marked by a rose or yellowish redness, tending in bad constitutions, to brown, or even to purple, in all cases terminating by a defined edge on the white surrounding skin. It frequently spreads with great rapidity, so that the limb, and even the whole skin of the body, may be in time affected by it; the redness subsiding, and even disappearing in one part, whilst it extends in another direction. When this inflammation attacks young and otherwise healthful persons of apparently good constitutions, it should be treated by emetics, purgatives, and diaphoretics, in the first instance, with perhaps, in some cases, bleeding. When the habit of body is not supposed to be healthy, bleeding is inadmissible ; and stimulating diaphoretics, combined with camphor and ammonia, will be found more beneficial after emetics and purgatives; and these remedies may in turn be followed by quinine and the mineral acids, with the infusion and tincture of bark. Little reliance can be placed on large doses of cinchona in powder, which nauseate and therefore distress. When the inflammation extends deeper than the skin, into the areolar or cellular tissue, it partakes more of the nature of the healthy suppurative inflammation commonly called phlegmonous, is accompanied by the formation of matter, and tends to the sloughing or death of this tissue at an early period. The redness, in this case, is of a brighter colour, although equally diffuse, and with a determined edge; the limb is more swollen, tense, and soon becomes quagmiry to the touch. The skin is then undermined, and soon loses its life, becomes gangrenous in spots, and separates, giving exit to the slough and matter, which now pervade the whole extremity affected. If the patient survive, it is probably with the loss of the whole of the skin and cellular substance of the limb. As soon as the inflamed part communicates the springy fluctuating sensation approaching to, but not having arrived at the quagmiry feel alluded to, an incision should be made into it, when the areolse or cells of the cellular tissue will be seen of a light leaden colour, and of a gelatinous appearance arising from the fluid secreted into them now nearly in the act of being converted into pus. The septa dividing the tissue into cells have not, at this period, lost their life, and the fluid hardly exudes, as it will be found to do a few hours later, when the matter deposited has beWhen this change has taken place, the come purulent. patient is in danger, and if relief be not given, he will often die under the most marked symptoms of irritative fever of a typhoid type. Nature herself sometimes gives the required relief, by the destruction of the superincumbent skin; but this part is tough, offers considerable resistance, and does not readily yield until the deep-seated fascia is implicated, and the muscular parts are about to be laid bare,
No. 1488.
II ’,
’, ’,
1852.
An incision made into the inflamed part, through the cellular tissue, and down to the deeper-seated fascia, which should not be divided in the first instance, gives relief. One of four inches in length usually admits of a separation of its edges to the amount of two inches, by which the tension of the skin, which principally causes the mischief which follows the inflammation, is removed. As many incisions are required as will relieve this tension, according to the extent of the inflammation, which is also relieved by the flow of blood, which requires attention, as it is often considerable, particularly if the deep fascia be divided, on which the larger vessels are found to lie. If the necessary incisions are delayed until the quagmire feeling is fully established, the skin above it is generally undermined and dies. The following case is given as the first known in London in which long incisions were made for the cure of this disease; and their effect in relieving the constitutional irritation is so strongly marked as to need no further explanation. Thomas K-, aged forty, a hard drinker, was admitted into the Westminster Hospital, under my care, on the 21st of October, 1823, having fallen and injured his left arm against a stool four days previously. On the 30th, the skin being very tense, the part springy and yielding the boggy feel described, pulse 120, mind wandering, I proposed, in consultation with my colleagues, to make incisions into the part; but which were considered to be unusual and improper. On the 31st, the pulse being 130, and everything indicating a fatal termination, I refrained from any further consultation, although directed by the rules of the hospital; and, after my old Peninsular fashion, made an incision eight inches long into the back of the arm; and another of five, on the under edge, in the line of the ulna, down to the fascia, which was in part divided; and one vessel bled freely. The next day, Nov. 1, the pulse was 90 ; the man had slept, and said he had had a good night. The incision on the back of the arm was augmented to eleven inches; and from this time he gradually recovered. This case has been the exemplar on which this most successful practice has been followed throughout the civilized world. When this kind of inflammation attacks the scrotum, which it sometimes although rarely does, as a sporadic disease, and independent of any urinary affection; incisions into it should be made with great caution and of small extent, in consequence of the loss of blood which will ensue from the great vascularity of the part. They should be confined to, and not extend beyond, the parts obviously falling into a state of slough or of mortification. 26. Mortification is the last and most fatal result of inflammation, although it may occur as a precursor of it in the neighbouring parts, and not as a consequence. The essential distinction is, between that which is idiopathic or constitutional and that which is local, and has not existed long enough to implicate the system at large, or to become constitutional. Idiopathic or constitutional mortification, sphacelus or gangrene, may be humid or dry. Humid when the death of the part has been preceded by inflammation and a great deposition of fluid in it, followed by putrefaction and decomposition, as after an attack of erysipelas following an injury. It may then be said to be acute. Dry when preceded by little or no deposition of fluid in it, and followed by a drying, shrivelling, and hardening of the part, nearly in its natural form and shape, unless exposed to external causes usually leading to putrefaction. This, when it occurs in old persons, or in those who have lived on diseased rye or other food, may be called chronic. The gangrene which follows wounds has been termed traumatic, which explains nothing but the fact of its following an
injury.
Local mortification may be the effect of great injury applied direct to the part, or of an injury to the great vessels of the limb. It may occur from intense cold freezing the part, or from intense heat burning or destroying it. 27. It sometimes happens that a cannon-ball strikes a limb, and without apparently doing much injury to the skin, so completely destroys the internal textures, that gangrene takes place almost without an effort on the part of nature to prevent it. This kind of injury was formerly attributed to the wind of a ball; but no one who has seen noses, ears, &c., injured or carried away, and all parts of the body grazed, without such mischief following, can believe that either the wind, or the collected by it can produce such effect. electricity The patient is sensible of having received a severe blow on the part affected, which does not show much external sign of L
234 the skin being often apparently unhurt only grazed; injury, themotion of the part is lost, and is insensible; the bone the bones but in either be or
it
or
case broken, may or may not sufferer, injury be in the leg, is incapable of putting it to the ground. After a short time the limb changes colour in the same manner as when severely bruised, and the necessary changes rapidly go on to gangrene. The limb swells, but not to any extent, and more from extravasation between the muscles and the bones than from inflammation, which, although it is attempted to be set up, never attains to any height. The mortification which ensues tends to a state between the humid and the dry, and rather more to the latter than the former. These cases are not of frequent occurrence, and are not commonly observed until after the blackness of the skin, and the want of sensibility and motion, attract attention; for the patient is generally stupified at first by the blow, and the part or parts about the injury feel benumbed. I made these cases an object of particular research after the battle of Waterloo, but could find only one among the British wounded. The man stated that he had received a blow on the back part of the leg, he believed from a cannon-shot, which brought him to the ground, and stunned him considerably. On endeavouring to move, he found himself incapable of stirring, and the sensibility and power of motion in the limb were lost. The leg gradually changed to a black colour, in which state he was carried to Brussels. When I saw it, the limb was black, apparently mortified, and cold to the touch; the skin was not abraded; the leg was not so much swollen as in cases of humid gangrene; the mortification had extended nearly as high as the knee; there was no appearance of a line of separation; and the appearances of inflammation were so slight, that amputation was performed immediately above the knee. On dissecting the limb, I found that a considerable extravasation of bloody fluid had taken place below the calf of the leg, and in the cavity thus formed some ineffectual attempts at suppuration had commenced. The periosteum was separated from the tibia and fibula; the popliteal artery was, on examination, found closed in the lower part of the ham by coagulated lymph, proceeding from a rupture of the internal coat of the vessel. Two inches below this the posterior tibial and fibular arteries were completely torn across, and gave rise, in all probability, to the extravasation. The operation was successful. The proper surgical practice in such cases is to amputate as soon as the extent of the injury can be ascertained, in order that a joint may not be lost. It is hardly necessary to give a caution not to mistake a simple bruise or ecchymosis for mortification. To prevent such an error leading to amputation, the Baron Larrey has directed an incision to be previously made into the part, and to this
if the
there can be no objection, 27. When a large shot or other solid substance has injured a limb to such an extent only as admits of the hope of its being possible to save it, this hope is sometimes found to be futile, at the end of three or four days, from a failure of power in the part below the injury to maintain its life for a longer time: mortification is obviously impending. In military warfare, uncontrollable events often render amputation unavoidable in such a case. Under more favourable circumstances, the surgeon should be guided by the principle laid down of constitutional and local mortification; and although the line cannot perhaps be distinctly drawn between them at the end of three, four, or more days, it will be better to err on the side of amputation than of delay. If the limb should be swollen or inflamed to any distance, with some constitutional symptoms, in a doubtful habit of body, the termination will in general be unfavourable, whichever course be adopted, more particularly if the amputation must be done above the knee. The consideration of the circumstances in which the patient is placed, his age, and his habit of body, should have great weight in forming a decision, in the first instance, as to the propriety of
attempting to save the limb.
28. Whenever the main artery of a limb is injured by a musket-ball, mortification of the extremity will frequently be the result, particularly if it be the femoral artery; and it will be of certain occurrence if both artery and vein are injured, although they may not be either torn or divided. There may not then, be such a sudden loss of blood, in considerable quantity, as to lead to the suspicion of the vessel being injured. The fact is known from the patient’s soon complaining of coldness in the toes and foot, accompanied by pain, felt especially in the back part or calf of the leg, together with an alteration of the appearance of the skin of the toes and instep, which, when once seen, can never be mistaken. It assumes
the colour of
a
tallow candle, and
soon
of mottled soap;
although there may be little loss of temperature under ordi-
nary circumstances of comfort, there is a feeling of numbness, but it is only at a later period that the foot becomes insensible. This change marks the extent of present mischief. The temperature of the limb above is somewhat higher than natural, and some slight indications of inflammatory action may be observed as high as theham, and the upper part of the tibia in front; and it is at these parts that the mortification usually stops when it is arrested. The general state of the patient, during the first three or four days, is but little affected, and there is not that appearance of countenance which usually
accompanies mortification from constitutional causes. In a day or two more, the gangrene will frequently extend, when the limb swells, becomes painful, and more streaked or mottled in colour; the swelling passes the knee, the patient becomes feverish, anxious, delirious, and dies. An extreme case will best exemplify the practice to be pursued. A soldier is wounded by a musket-ball at the upper part of the middle third of the thigh, and on the third day
the great toe is clearly gangrenous. What is to be done1 Wait with the hope that the mortification will not extend. Suppose that the approaching mortification has not been observed until it has invaded the instep. What is to be done? Wait, provided there are no constitutional symptoms; but if they should present themselves, or the discoloration of the skin should spread, amputation should be performed forthwith, for such cases rarely escape with life. Where in such a case should the amputation be performed? I formerly recommended that it should be done at the part injured in the thigh. I do not now advise it to be done there at an early period, when the foot only is implicated, but immediately below the knee, at that part where, if mortification ever stops and the patient survives, it is usually arrested; for the knee is by this means saved, and the great danger attendant on an amputation at the upper third of the thigh is avoided. The upper part of the femoral artery, if divided, rarely offers a secondary haemorrhage. The lower part, thus deprived by the amputation of its reflex blood, can scarcely do so; and if it should, thebleeding may be suppressed by a compress. The blood will be dark-coloured. If the upper end should bleed, the blood will be arterial, and by jets, and the vessel must be secured by ligature. 29. When from some cause or other amputation has not been performed, and the mortification has stopped below the knee, it is recommended to amputate above the knee after a line of separation has formed between the dead and the living parts. This should not be done. The amputation should be performed in the dead parts, just below the line of separation, in the most cautious and gentle manner possible; the mortified parts which remain being allowed to separate by the efforts of nature, a joint will be saved, and the patient have a much better chance for life. 30. A wound of the axillary artery rarely leads to mortifica. tion of the fingers or hand. If it should do so, the principle of treatment should be similar, although the saving of the elbow is not so important as that of the knee; neither is the amputation in the axilla, below the tuberosities of the humerus, as dangerous as that above the knee. 31. Mortification, after the sudden application of intense cold or heat, is to be treated on similar principles. 32. When a nerve, or plexus of nerves, conveying sensation and motion, and going to a part or an extremity of the body, is divided, the part or limb is deprived of three great qualitiesmotion, sensation, and the power of resisting with effect the application of a degree of heat or of cold which is innocuous when applied in a similar manner to the opposite or sound extremity. In other words, it will be scalded by hot water and frost-bitten by iced water, which are harmless when applied to another and a healthy part. An officer received, at the battle of Salamanca, two balls, one underneath the left clavicle, which was supposed to have divided the brachial plexus of nerves, as the arm dropped motionless and without sensation to the side. The other ball passed through the knee-joint, which suppurated. The left side of the chest became affected; he suffered from severe cough, followed by hectic fever, and was evidently about to sink. As a last chance, I amputated his leg above the knee, after which he slowly recovered. Fourteen years afterwards, he showed me his arm in the same state, and told me he had been indicted for a rape, but that the magistrates, seeing the wooden leg and the useless arm, in admitting the attempt, would not assent to the committal of that offence. 33. When one nerve only of several going to an extremity, such as the arm and hand, is divided, the loss sustained is confined to the part more immediately supplied by the’ injured nerve. Thus, if the ulnar nerve only is divided, the little
235 and the
muscles, Ithe he
and lameness, together with the usual incapability or cold, particularly the latter, against which is peculiarly obliged to guard. The skin shows no sign of discoloration or derangement. Position gives the explanation why the ball took such a peculiar course; the symptoms show the nature of the injury. From other effects he has sensibility is after a time recovered. 34. If any foreign substance should lodge in, and continue to perfectly recovered, but his leg is comparatively as useless to as an artificial one, whilst it is a constant source of irritate the nerve, the wounded part often becomes so extremely misery. painful as not to be borne. The nerve at that part forms a suffering, sometimes aggravated to that ofmortification 38. The cases related elsewhere, of tumour of a most painful character, requiring removal, or in taking extreme cases even the amputation of the extremity. place in the foot and leg, after the division of the principal 35. After an ordinary amputation, the extremity of a nerve artery in the thigh, show that the maintenance of the life of a enlarges so as to resemble a leek, and if this should adhere to part depends on the blood. The cases now related show that the cicatrix of the wound, painful symptoms, referred to the neither an injury nor the division of the principal nerve, nor, toes and other parts of the removed leg, are experienced often perhaps, all the nerves going to a part, will destroy that life. to an almost unbearable degree, when it must be treated in a The complete failure of the circulation in a part such as the similar manner to obtain relief. The pain apparently felt in impairs, but does not totally destroy, the sensibility imand referred to the toes is merely the effect of irritation of parted by the nerves, until some hours-nay, days-after the the extremity of the nerve. of life has taken place, nor until decomposition is about 36. Wounds or injuries of nerves, which do not entirely to occur. An injury then to the nerve causes great pain in divide the trunk or a principal branch given off from a plexus parts supplied by it; some loss of the power of motion, of nerves, may give rise to general as well as local symptoms- some deprivation of its ordinary sensibility, as shown by a that is, by sympathy, connexion, or continuity of disease, feeling of numbness; and an incapability, to a certain extent, other nerves and organs of the body are affected. This applies of resisting heat or cold. When all the nerves are divided, the also to the spinal marrow, when the injury does not destroy at power of moving the limb is lost, as well as its sensibility in once. General Sir James Kempt was wounded at the storming a general sense. The temperature remains at a natural of the castle of Badajos, on the inside of the left great toe, by a standard under ordinary circumstances, but no extra evolution musket-ball, which from the appearance of a slit-like opening of heat can take place by which cold is resisted, nor any was supposed to have rebounded from the bone, but was disabsorption of it which perhaps renders the application of a covered a fortnight afterwards, flattened and lying between this high temperature, particularly when combined with moisture, and the next toe. Inflammation had ensued, followed by great The circulation is capable of maintaining the irritability and numerous spasmodic attacks, appearing to render ordinary heat of a part although it is deprived of the inlocked-jaw probable. The spasms soon became more general, fluence of the special nerves of sensation and of motion, extending from the foot to the head, but tetanus did not take but a greater evolution of heat appears to depend on someplace; on his return to England, they gradually subsided, thing communicated by the nerves in a state of integrity. but he did not sleep at night for a year. After the battle of In the case of Sir P. Broke, this something appeared to be Waterloo the spasms became more frequent and troublesome, derived from the brain, on which part the wound was inflicted, attacking the muscles at the back of the neck and throat, and the transmission of which was interrupted by the injury. causing considerable anxiety. The attack was often traced The evolution of animal heat has of late been supposed to be to exposing the foot to cold or to undue pressure, and fre- dependent on electricity, from the resemblance which exists quently to derangement of stomach, although he was most between it and the nervous power, although the attempts to regular in diet. After the lapse of six or seven years these identify them have not been successful. That the evolution severe symptoms subsided, but he now, at the end of forty of heat is the result of nervous power, appears to be indisyears, suffers occasionally from them. putable ; in what that power consists, physiologists have yet Admiral Sir Philip Broke received a cut with a sword on to ascertain. 39. The best means of mitigating the pain, independently of boarding the Chesapeake, on the left side of the back of the head, which went through his skull, rendering the brain visible, the application of heat-and cold rarely does good, which the which wound healed in six months, although splinters of bone sufferer soon finds out-is by the application of stimulants to came away for a year. A second cut on the right side did not the whole of the extremity affected, followed bv narcotics. penetrate the bone. After a temporary paralysis of the right The tinctures of iodine and lyttse, the oleum terebinthae, the side, he recovered with a loss of power and a disordered sen- oleum tiglii, the liquor ammonise or the veratria, in the form of sation in the second, third, and little fingers of the right hand, an embrocation, of such strength as will cause a good deal of irritation on the skin, short, however, of producing any aggravated by cold weather and by mental anxiety. Seven years afterwards he fell from his horse and suffered serious eruption. After the parts have been well rubbed, from concussion of the brain, which added to his former sen- opium, belladonna, or henbane should be applied in the form sations, by rendering the left half of his whole person incapable of ointment; or the tinctures of opium, henbane, or aconite of resisting cold, or of evolving heat. In a still atmosphere may in turn be applied on linen. Great advantage has been abroad, at 68° Fahr., he said, the left side requires four coatings derived in many neuralgic pains from the application of aconiof stout flannel, which are augmented as the thermometer tine carefully prepared, in the proportion of one grain to a descends every two degrees and a half, to prevent a painful drachm of lard, at which strength it will sometimes irritate sense of cold; so that when it stands at the freezing point the almost to vesication, as well as allay pain. When the pains return from exposure to cold, particularly quantity of clothing on the affected side becomes extremely burdensome. When exposed to a breeze, or even in moving in the lower extremity, great advantage has been against the air, one or even two oilskin coverings are necessary from cupping on the loins, from purgatives, opiates, and the in addition, to prevent a sensation of piercing cold driving warm bath. Benefit has been obtained occasionally from quinine, belladonna, aconite, and stramomium, administered through the whole -frame. Moderate horse exercise and generous diet improved the internally. general health; the warm-bath caused a distressed effect; the shower-bath, cold or tepid, increased the paralytic affection. Frictions with remedies of all kinds increased it also, and so did ON A CASE OF CONGENITAL STRANGULATED INGUINAL HERNIA. sponging with vinegar-and-water, as well as any violent stimulating quick excitement, or earnest attention to any particular ARTIFICIAL ANUS; DEATH: WITH REMARKS. OPERATION; subject. The admiral died unrelieved, twenty-six years after BY HENRY BULLOCK, ESQ., the receipt of the injury, of disease of the bladder. RESIDENT SURGEON TO ST. MARY’S HOSPITAL. 37. Brigade-Major Bissett was wounded, on horseback, in the Kaffir war, by a musket-ball, which entered on the J. S-, aged thirty-eight, married, a tobacco-pipe maker, outside of the lower part of the left thigh, passed upwards across the perinseum, wounding the rectum within the anus- was admitted into St. Mary’s Hospital, under Mr. Coulson, at from which part he lost a quantity of blood-and came out ten A.M. on the 6th November, 1851. He stated that ever since through the pelvis on the opposite side. The course of a boy he had had a rupture in the right groin, which had this ball was accounted for by the fact that he saw the always been reducible. He had worn a truss, which he was Kaffir who shot him standing some yards below him when he in the habit of leaving off during the night, up to about ten fired. The ball, in its passage upwards and across the thigh, days ago, when, owing to the spring having broken, he left it injured the great sciatic nerve, and the consequence is con- off for about two hours, during which time he was walking tinued pain in the toes, instep, and foot, with contraction of about; soon after this he complained of pain in the groin
adjacent side of the ring-finger suffer, perhaps degree the inner side of the thumb; if the median nerve, the thumb and other fingers; if the radial, the back of the hand, next the thumb. In some instances there seems to be a kind of collateral communication, by which a degree of
finger
in
some
of bearing heat
him
foot, loss
the
harmless.
derived
___