Читать книгу Commentaries on the Surgery of the Npoleonic War in Portugal, Spain, France, - G. J. Guthrie - Страница 5

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ON INFLAMMATION, MORTIFICATION, ETC.

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 be 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 blood-letting; and especially 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, but 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, while it extends in another direction. When this inflammation attacks young and otherwise healthful persons of apparently good constitution, 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; 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; they 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 color, although equally diffuse, and with a determined edge; the limb is more swollen and tense, and soon becomes quagmiry to the touch. The skin is then undermined, and soon loses its life, becomes ash colored and gangrenous in spots, and separates, giving exit to the slough and matter which now pervade the whole extremity affected. If the patient survive, it will probably be with the loss of the whole of the skin and the cellular substance of the limb.

As soon as the inflamed part communicates the springy, fluctuating sensation approaching, but not yet arrived at the quagmiry feel alluded to, an incision should be made into it, when the areolæ or cells of the cellular tissue will be seen of a bright leaden color, and of a gelatinous appearance, arising from the fluid secreted into them, being 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 become purulent. When this change has taken place, the patient is in danger, and if relief be not given, he will often sink 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.

An incision made into the inflamed part through the cellular tissue, down to the deep-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, but that 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 be delayed until the quagmiry 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 Key, 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 140, 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; one vessel bled freely. The next day, November 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 that time he gradually recovered, being snatched as it were from the jaws of death.

This case, published at the time, has been the exemplar on which this most successful practice has been followed throughout the civilized world—a practice entirely due to the war in the Peninsula.

When this kind of inflammation attacks the scrotum, which it sometimes, although rarely, does, as a sporadic disease, independent of any urinary affection, incisions into it should be made with great caution, not extending beyond the discolored spots, in consequence of the loss of blood which would 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 neighboring 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, shriveling, and hardening of the part, nearly in its natural form and shape, unless exposed to external causes usually leading to putrefaction. The most remarkable instances have occurred in persons suffering from typhus fever, and exposed to cold, without sufficient covering or care. When it occurs in old persons, or in those who have lived on diseased rye or other food, it 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, etc. injured or carried away, and all parts of the body grazed, without such mischief following, can believe that either the wind, or the electricity collected by it, can produce such effect.

The patient is aware of having received a severe blow on the part affected, which does not show much external sign of injury, the skin being often apparently unhurt or only grazed; the power of moving the part is lost, and it is insensible. The bone or bones may or may not be broken, but in either case the sufferer, if the injury be in the leg, is incapable of putting it to the ground. After a short time the limb changes color 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 stupefied 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 endeavoring 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 color, 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 signs 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, as the knee was in this instance. 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, Baron Larrey has directed an incision to be previously made into the part, and to this there can be no objection.

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 favorable 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 unfavorable, 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 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, which ought only to be done in persons of good constitution and apparent strength.

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; 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, or in the heel, or across the instep, 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 color of a tallow candle, and soon the appearance of mottled soap. Although there may be little loss of temperature under ordinary 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 the ham, and the upper part of the tibia in front; 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 color; the swelling passes the knee, the thigh becomes œdematous, the patient more feverish and anxious, then 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 has become of a tallowy color and has lost its life. What is to be done? 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 appear to spread, amputation should be performed forthwith, for such cases rarely escape with life if it be not done. 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 hemorrhage. The lower part, thus deprived by the amputation of its reflex blood, can scarcely do so; and if it should, the bleeding may be suppressed by a compress. The blood will be dark colored. 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 mortification 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 qualities: motion, 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 or even cold water, which are harmless when applied to another and a healthy part.

An officer received, at the battle of Salamanca, two balls, one under 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 afterward 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, while admitting the attempt, would not assent to the committal of the 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 extreme part more immediately supplied by the injured nerve. Thus, if the ulnar nerve only be divided, the little finger and the adjacent side of the ring finger suffer, perhaps in some degree the inner side of the thumb and the adjoining fingers; 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 sensibility is after a time recovered.

34. If any foreign substance should lodge in and continue to irritate the nerve, the wounded part often becomes so extremely painful as not to be borne; the nerve at that part forms a tumor of a most painful character, requiring removal, or in extreme cases even the amputation of the extremity.

35. After an ordinary amputation, the extremity of a nerve enlarges so as to resemble a leek, and if this should adhere to the cicatrix of the wound, painful symptoms, referred to the toes and other parts of the removed leg, are experienced often to an almost unbearable degree; the end of the nerve should be removed. The pain apparently felt in and referred to the toes is merely the effect of irritation of the extremity of the nerve.

36. Wounds or injuries of nerves, which do not entirely divide the trunk, or a principal branch given off from a plexus of nerves, may give rise to general as well as to local symptoms; that is, by sympathy, connection, or continuity of disease, other nerves and organs of the body are affected. This applies also to the spinal marrow, when the injury does not destroy at once. General Sir James Kempt was wounded at the storming of the castle of Badajoz, on the inside of the left great toe, by a musket-ball which, from the appearance of a slit-like opening, was supposed to have rebounded from the bone, but was discovered a fortnight afterward flattened and lying between it and the next toe. Inflammation had ensued, followed by great irritability and numerous spasmodic attacks, appearing to render locked-jaw probable. The spasms soon became general, extending from the foot to the head, but tetanus did not take place. On his return to England, they gradually subsided, but he did not sleep at night for a year. After the battle of Waterloo the spasms became more frequent and troublesome, attacking the muscles at the back of the neck and throat, causing considerable anxiety. The attack was often traced to exposing the foot to cold or to undue pressure, and frequently to derangement of stomach, although he was most regular in diet. After the lapse of six or seven years these severe symptoms subsided; but during the last forty years of his life he suffered occasionally from them.

Admiral Sir Philip Broke received a cut with a sword on boarding the Chesapeake, on the left side of the back of the head, which went through his skull, rendering the brain visible; the wound healed in six months, although splinters of bone came away for a year. A second cut on the right side did not penetrate the bone. After a temporary paralysis of the right side, he recovered, with a loss of power and a disordered sensation in the second, third, and little fingers of the right hand, aggravated by cold weather and by mental anxiety.

Seven years afterward, he fell from his horse, and suffered from concussion of the brain, which added to his former sensations by rendering the left half of his whole person incapable of resisting cold, or of evolving heat. In a still atmosphere abroad, at 68° Fahr., he said, “the left side requires four coatings of stout flannel, which are augmented as the thermometer descends every two degrees and a half, to prevent a painful sense of cold; so that when it stands at the freezing point the quantity of clothing of the affected side becomes extremely burdensome. When exposed to a breeze, or even in moving against the air, one or even two oilskin coverings are necessary in addition, to prevent a sensation of piercing cold driving through the whole frame. Moderate horse exercise and generous diet improved the general health; the warm bath caused a distressing effect; the shower bath, cold or tepid, increased the paralytic affection. Frictions, with remedies of all kinds, increased it also, and so did sponging with vinegar and water, as well as any violent, stimulating, quick excitement, or earnest attention to any particular subject. The Admiral died unrelieved, twenty-six years after the receipt of the injury, of disease of the bladder.”

37. Brigade-Major Bissett was wounded on horseback, in the Kaffir war, by a musket-ball, which entered on the outside of the lower part of the left thigh, passed upward across the perineum, wounding the rectum within the anus—from which part he lost a quantity of blood—and came out through the pelvis on the opposite side. The course of this ball was accounted for by the fact that he saw the Kaffir who shot him standing some yards below him when he fired. The ball, in its passage upward and across the thigh, injured the great sciatic nerve, and the consequence is continued pain in the toes, instep, and foot, with contraction of the muscles, and lameness, together with the usual incapability of bearing heat or cold, particularly the latter, against which he 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 perfectly recovered, but his leg is comparatively useless, while it is a constant source of suffering.

38. The cases related in the Lectures on wounds of arteries, of mortification taking place in the foot and leg, after the division of the principal artery in the thigh, show that the maintenance of the life of a part depends on the blood. The cases now related show that neither an injury nor the division of the principal nerve, nor, perhaps, of all the nerves going to a part, will destroy that life. The complete failure of the circulation, in a part such as the foot, impairs, but does not totally destroy, the sensibility imparted by the nerves, until after the loss of life has taken place, or until decomposition is about to occur. An injury then to the nerve causes great pain, not usually at the part injured, but in the extreme parts supplied by it; some loss of the power of motion; some deprivation of its ordinary sensibility, as shown by a feeling of numbness, and an incapability, to a certain extent, of resisting heat or cold. When all the nerves have been divided, the power of moving the limb is lost, as well as its sensibility in a general sense. The temperature remains at a natural standard under ordinary circumstances, but no extra evolution of heat can take place by which cold is resisted, nor any absorption of it, which perhaps renders the application of a high temperature, particularly when combined with moisture, dangerous. The circulation is capable of maintaining the ordinary heat of a part, although it is deprived of the influence of the special nerves of sensation and of motion; but a greater evolution of heat appears to depend on something communicated by the nerves in a state of integrity. In the case of Sir P. Broke, this something appeared to be derived from the brain, on which part the wound was inflicted, and the transmission of which was interrupted by the injury. The evolution of animal heat has of late been supposed to be dependent on electricity, from the resemblance which exists between it and the nervous power, although the attempts to identify them have not been successful. That the evolution of heat is the result of nervous power, appears to be indisputable; in what that power consists, physiologists have yet to ascertain.

39. The best means of mitigating the pain, independently of the application of warmth—and cold rarely does good, as the sufferer soon finds out—is by the application of stimulants to the whole of the extremity affected, followed by narcotics. The tinctures of iodine and lytta, the oleum terebinthinæ, the oleum tiglii or cajeputi, the liquor ammoniæ or veratria, may be used in the form of an embrocation, of such strength as to cause some irritation on the skin, short, however, of producing any serious eruption. After the parts have been well rubbed, opium, belladonna, or henbane may be applied in the form of ointment; or the tincture of opium, henbane, or aconite may in turn be applied on linen. Great advantage has been derived in many neuralgic pains from the application of an ointment of aconitine, carefully prepared, in the proportion of one grain to a drachm of lard, at which strength it will sometimes irritate almost to vesication, as well as allay pain.

When the pains return from exposure to cold, particularly in the lower extremity, great advantage has been derived from cupping on the loins, from purgatives, opiates, and the warm bath. Benefit has been obtained occasionally from quinine, and from belladonna, aconite, and stramonium, administered internally in small doses frequently repeated, but not suffered to accumulate without purgation; as the accumulated effects are sometimes dangerous.