In scorbutic habits, particularly in sailors after long voyages, in soldiers from an unhealthy encampment, or after a siege, and in prisoners after confinement, ulcers break out chiefly in the lower extremities, which discharge a thin ichor, and sometimes terminate in mor-tification. Instances are also recorded of mortifications rapidly coming on without any evident cause.
Other causes are ligatures, wounds, fractures, where the soft parts are greatly bruised or lacerated; aneu-tisms, or ruptured arteries, with whatever impedes the influence of the nervous power, or the flow of blood from the heart. From these causes, mortification often occurs in palsied limbs, or is the effect of severe long continued cold, q. v. Compression of the spinal marrow in cases of distorted vertebrae, or. of other tumours in the course of the larger nerves, equally produce it, by first inducing palsy.
The event of mortification is always doubtful; and when the cause is irrecoverable debility, obstructions which art cannot remove, or ossifications of the arteries, we can scarcely expect a cure. Internal mortifications are usually beyond the reach of medicine; yet we see in cases where the operation is performed for strangulated hernia a beginning blackness, not followed in some cases by any fatal event; and find that even a portion of intestine may be thrown off, after intususceptio, in which internal mortification must have preceded. We should not, therefore, relax in our efforts, when appearances of internal mortification have come on; and, in fact, we find in enteritis the most threatening symptoms of this kind apparently relieved.
The most important symptom to guide us in cases of mortification, is the appearance of separation. When the general principle of the disease, in the constitution, is checked, a red line, sometimes considerably above the mortified part, appears. At this line the dead part drops from the living; and, when it is discovered, amputation above that line will greatly save the strength of the patient: were the natural separation suffered to go on, amputation would be afterwards necessary, if the stump is expected to be ever useful. In cases, however, where, from the violence of the bruise, mortification appears inevitable, amputation, previous to its coming on, will succeed, at no great distance from the wounded part, if above the place where it is bruised, or to which inflammation has extended.
When mortification appears to have taken place after internal inflammation, we have said our endeavours must not be relaxed, but we must check all evacuations, and support the strength with more generous nourishment, give wine so far as the original disease will permit, occasionally bark, and more certainly opium.
In external mortifications, from inflammation, it has been common immediately to give bark. But this is not always necessary, and sometimes injurious. If the increased action of the vessels still continues, it must be moderated by a stimulus, a little below that which supports the inflammation; and it is in this state that the application of a solution of muriated ammonia with vinegar is peculiarly useful. At this period also, opiates will be advantageous. When the disease has proceeded farther, and the part is wholly dead, the warmer applications, soon to be mentioned, will be necessary. It has been usual to direct, in such cases, incisions or scarifications down to the living portion of the limb. It has been practised, and opposed, without sufficient foundation. It is often useful to admit of the access of the stimuli to the living part, to assist the separation; and there is no danger from the absorption of the putrid matter, as has been supposed. Yet, on the whole, the advantages of this plan, in practice, do not appear to be considerable.
In those mortifications which attend jail and hospital fevers, the bark, with cordials, each in the fullest doses, are absolutely necessary; nor are there any limits to the exhibition, but what arise from the situation of the patient. In such cases, all abscesses must be opened very early. We cannot wait for a proper purulent matter, which nature is most frequently unable to form; for the discharge is most often fetid and sanious.
The topical mortifications are most frequent; and, in these, Mr. Pott has taught us the superior advantages of opium. In general, this medicine is indicated when great pain has preceded; and it is probable that, as excess of contraction lessens the irritability of muscular fibres, so excess of excitement will impair the nervous energy. Opium, therefore, as diminishing the cause, will contribute to lessen the effect. Whether opium will add to the efficacy of other medicines, or will, alone, relieve diseases of this kind, has not yet been ascertained. We have reason to think it will prove a useful addition, in the greater number of cases.
If opium fails in the painful gangrenes, proceeding from ossifications, we know not what can be substituted. Bark, wine, and other cordials will have little effect; nor will any thing succeed but amputation. Where, however, must we amputate, or where does ossification end ? and in an old, worn out, debilitated frame, is the operation advisable ? To add a few weeks to a decaying constitution will not justify what Dr. Aitkin calls an Herculean experiment.
The rest of the practice is empirical. Bark, wine, ardent spirits, and opium, must be given in doses equal to the emergency, and often accumulated with great rapidity. It might perhaps render the practice less empirical, if surgeons were to distinguish more accurately when stimulants and when antiseptics were necessary. The list of stimulants is unusually long; but the order indirecta, including wine, alcohol, & c. is of equivocal use, as followed by loss of tone, unless the application is continued. As powerful antiseptics also they have been preferred, and we should also remember, that in general, when the disease is first checked, nature exerts all her powers to continue the salutary process. We add to the antiseptic power of these stimulants by camphor, which may be properly combined with them, and sometimes by the warmer essential oils, which may perhaps be more often used with advantage; and the effects of all are increased, by their being heated to a degree so high as the patient can bear. In local mortifications from debility, the antiseptics are often only necessary; and of these the myrrh is frequently very useful, and in cases of a high degree of faetor, the carrot poultice, the charcoal, the effervescing poultices, particularly with the oak bark, and the cummin seed, are highly advantageous. In every situation of this kind, however, the constitution must be supported, by a generous diet; by wine, frequently by bark.
In many instances, the bark is inadmissible, either from fulness, asthma, or other constitutional complaints. In these circumstances, wine, probably opium, ammonia, with stimulant applications of the greatest efficacy, must be employed. We have not found that the other bitters will supply the place of the bark; but the camomile flowers have been recommended, though modern practice appears to rank them among the more inert remedies.
Antiseptic poultices are of different kinds. The astringents, of which the chief is the oak bark, are highly useful; and this, joined with fermenting substances, is often highly useful. The addition of charcoal is said to correct the foetor, and it may add also to the antiseptic power. Since, however, it was introduced by the recommendation of the first Monro, the bark has been implicitly trusted.
We might add a hint, that amputation has been often employed too early, and that ecchymosis has been mistaken for mortification. Yet, as we can lay down no general rules for the conduct in cases of emergency, we would not insinuate doubts which might be prejudicial to the character of the surgeon, without reason or foundation.
The tendency to mortification from scorbutic affections must be obviated by fresh vegetables, and the native vegetable acids. Those from tumours of the spine or other parts, from palsies, & c. must be relieved by remedies adapted to the original affection.
Boerhaavii Aphorismi. Hildanus de Gangraena et Sphacelo. Heister's Surgery. Kirkland on Pott's Remarks on Fractures. Pott's Works. Bell on Ulcers, edit. 3. p. 93 - 122. Kirkland's Medical Surgery, vol. ii. p. 291 - i33. London Medical Transactions. vol. iii. p. 47. Pearson's Principles of Surgery, vol. i. p. 105. White's Surgery, p. 8.