Manual of Surgery Volume I Part 11

#Diabetic Gangrene.#--This form of gangrene is p.r.o.ne to occur in persons over fifty years of age who suffer from glycosuria. The arteries are often markedly diseased. In some cases the existence of the glycosuria is unsuspected before the onset of the gangrene, and it is only on examining the urine that the cause of the condition is discovered. The gangrenous process seldom begins as suddenly as that a.s.sociated with embolism, and, like senile gangrene, which it may closely simulate in its early stages, it not infrequently begins after a slight injury to one of the toes. It but rarely, however, a.s.sumes the dry, shrivelling type, as a rule being attended with swelling, dema, and dusky redness of the foot, and severe pain. According to Paget, the dead part remains warm longer than in other forms of senile gangrene; there is a greater tendency for patches of skin at some distance from the primary seat of disease to become gangrenous, and for the death of tissue to extend upwards in the subcutaneous planes, leaving the overlying skin unaffected. The low vitality of the tissues favours the growth of bacteria, and if these gain access, the gangrene a.s.sumes the characters of the moist type and spreads rapidly.

The rules for amputation are the same as those governing the treatment of senile gangrene, the level at which the limb is removed depending upon whether the gangrene is of the dry or moist type. The general treatment for diabetes must, of course, be employed whether amputation is performed or not. Paget recommended that the dietetic treatment should not be so rigid as in uncomplicated diabetes, and that opium should be given freely.

The _prognosis_ even after amputation is unfavourable. In many cases the patient dies with symptoms of diabetic coma within a few days of the operation; or, if he survives this, he may eventually succ.u.mb to diabetes. In others there is sloughing of the flaps and death results from toxaemia. Occasionally the other limb becomes gangrenous. On the other hand, the glycosuria may diminish or may even disappear after amputation.

#Gangrene a.s.sociated with Spasm of Blood Vessels.#--#Raynaud's Disease#, or symmetrical gangrene, is supposed to be due to spasm of the arterioles, resulting from peripheral neuritis. It occurs oftenest in women, between the ages of eighteen and thirty, who are the subjects of uterine disorders, anaemia, or chlorosis. Cold is an aggravating factor, as the disease is commonest during the winter months. The digits of both hands or the toes of both feet are simultaneously attacked, and the disease seldom spreads beyond the phalanges or deeper than the skin.

The first evidence is that the fingers become cold, white, and insensitive to touch and pain. These attacks of _local syncope_ recur at varying intervals for months or even years. They last for a few minutes or even for some hours, and as they pa.s.s off the parts become hyperaemic and painful.

A more advanced stage of the disease is known as _local asphyxia_. The circulation through the fingers becomes exceedingly sluggish, and the parts a.s.sume a dull, livid hue. There is swelling and burning or shooting pain. This may pa.s.s off in a few days, or may increase in severity, with the formation of bullae, and end in dry gangrene. As a rule, the slough which forms is comparatively small and superficial, but it may take some months to separate. The condition tends to recur in successive winters.

The _treatment_ consists in remedying any nervous or uterine disorder that may be present, keeping the parts warm by wrapping them in cotton wool, and in the use of hot-air or electric baths, the parts being immersed in water through which a constant current is pa.s.sed. When gangrene occurs, it is treated on the same lines as other forms of dry gangrene, but if amputation is called for it is only with a view to removing the dead part.

#Angio-sclerotic Gangrene.#--A form of gangrene due to _angio-sclerosis_ is occasionally met with in young persons, even in children. It bears certain a.n.a.logies to Raynaud's disease in that spasm of the vessels plays a part in determining the local death.

The main arteries are narrowed by hyperplastic endarteritis followed by thrombosis, and similar changes are found in the veins. The condition is usually met with in the feet, but the upper extremity may be affected, and is attended with very severe pain, rendering sleep impossible.

The patient is liable to sudden attacks of numbness, tingling and weakness of the limbs which pa.s.s off with rest--_intermittent claudication_. During these attacks the large arteries--femoral, brachial, and subclavian--can be felt as firm cords, while pulsation is lost in the peripheral vessels. Gangrene eventually ensues, is attended with great pain and runs a slow course. It is treated on the same lines as Raynaud's disease.

#Gangrene from Ergot.#--Gangrene may occur from interference with blood supply, the result of tetanic contraction of the minute vessels, such as results in ill-nourished persons who eat large quant.i.ties of coa.r.s.e rye bread contaminated with the _claviceps purpurea_ and containing the ergot of rye. It has also occurred in the fingers of patients who have taken ergot medicinally over long periods. The gangrene, which attacks the toes, fingers, ears, or nose, is preceded by formication, numbness, and pains in the parts to be affected, and is of the dry variety.

In this country it is usually met with in sailors off foreign ships, whose dietary largely consists of rye bread. Trivial injuries may be the starting-point, the anaesthesia produced by the ergotin preventing the patient taking notice of them. Alcoholism is a potent predisposing cause.

As it is impossible to predict how far the process will spread, it is advisable to wait for the formation of a line of demarcation before operating, and then to amputate immediately above the dead part.

BACTERIAL VARIETIES OF GANGRENE

The acute bacillary forms of gangrene all a.s.sume the moist type from the first, and, spreading rapidly, result in extensive necrosis of tissue, and often end fatally.

The infection is usually a mixed one in which anaerobic bacteria predominate. The anaerobe most constantly present is the _bacillus aerogenes capsulatus_, usually in a.s.sociation with other anaerobes, and sometimes with pyogenic diplo- and streptococci. According to the mode of action of the a.s.sociated organisms and the combined effects of their toxins on the tissues, the gangrenous process presents different pathological and clinical features. Some combinations, for example, result in a rapidly spreading cellulitis with early necrosis of connective tissue accompanied by thrombosis throughout the capillary and venous circulation of the parts implicated; other combinations cause great dema of the part, and others again lead to the formation of gases in the tissues, particularly in the muscles.

These different effects do not appear to be due to a specific action of any one of the organisms present, but to the combined effect of a particular group living in symbiosis.

According as the cellulitic, the dematous, or the gaseous characteristics predominate, the clinical varieties of bacillary gangrene may be separately described, but it must be clearly understood that they frequently overlap and cannot always be distinguished from one another.

#Clinical Varieties of Bacillary Gangrene.#--#Acute infective gangrene# is the form most commonly met with in civil practice. It may follow such trivial injuries as a pin-p.r.i.c.k or a scratch, the signs of acute cellulitis rapidly giving place to those of a spreading gangrene. Or it may ensue on a severe railway, machinery, or street accident, when lacerated and bruised tissues are contaminated with gross dirt. Often within a few hours of the injury the whole part rapidly becomes painful, swollen, dematous, and tense. The skin is at first glazed, and perhaps paler than normal, but soon a.s.sumes a dull red or purplish hue, and bullae form on the surface. Putrefactive gases may be evolved in the tissues, and their presence is indicated by emphysematous crackling when the part is handled. The spread of the disease is so rapid that its progress is quite visible from hour to hour, and may be traced by the occurrence of red lines along the course of the lymphatics of the limb.

In the most acute cases the death of the affected part takes place so rapidly that the local changes indicative of gangrene have not time to occur, and the fact that the part is dead may be overlooked.

[Ill.u.s.tration: FIG. 22.--Gangrene of Terminal Phalanx of Index-Finger, following cellulitis of hand resulting from a scratch on the palm of the hand.]

Rigors may occur, but the temperature is not necessarily raised--indeed, it is sometimes subnormal. The pulse is small, feeble, rapid, and irregular. Unless amputation is promptly performed, death usually follows within thirty-six or forty-eight hours. Even early operation does not always avert the fatal issue, because the quant.i.ty of toxin absorbed and its extreme virulence are often more than even a robust subject can outlive.

_Treatment._--Every effort must be made to purify all such wounds as are contaminated by earth, street dust, stable refuse, or other forms of gross dirt. Devitalised and contaminated tissue is removed with the knife or scissors and the wound purified with antiseptics of the chlorine group or with hydrogen peroxide. If there is a reasonable prospect that infection has been overcome, the wound may be at once sutured, but if this is doubtful it is left open and packed or irrigated.

When acute gangrene has set in no treatment short of amputation is of any avail, and the sooner this is done, the greater is the hope of saving the patient. The limb must be amputated well beyond the apparent limits of the infected area, and stringent precautions must be taken to avoid discharge from the already gangrenous area reaching the operation wound. An a.s.sistant or nurse, who is to take no other part in the operation, is told off to carry out the preliminary purification, and to hold the limb during the operation.

#Malignant dema.#--This form of acute gangrene has been defined as "a spreading inflammatory dema attended with emphysema, and ultimately followed by gangrene of the skin and adjacent parts." The predominant organism is the _bacillus of malignant dema_ or _vibrion septique_ of Pasteur, which is found in garden soil, dung, and various putrefying substances. It is anaerobic, and occurs as long, thick rods with somewhat rounded ends and several laterally placed flagella. Spores, which have a high power of resistance, form in the centre of the rods, and bulge out the sides so as to give the organisms a spindle-shaped outline. Other pathogenic organisms are also present and aid the specific bacillus in its action.

At the bedside it is difficult, if not impossible, to distinguish it from acute infective gangrene. Both follow on the same kinds of injury and run an exceedingly rapid course. In malignant dema, however, the incidence of the disease is mainly on the superficial parts, which become dematous and emphysematous, and acquire a marbled appearance with the veins clearly outlined. Early disappearance of sensation is a particularly grave symptom. Bullae form on the skin, and the tissues have "a peculiar heavy but not putrid odour." The const.i.tutional effects are extremely severe, and death may ensue within a few hours.

#Acute Emphysematous# or #Gas Gangrene# was prevalent in certain areas at various periods during the European War. It follows infection of lacerated wounds with the _bacillus aerogenes capsulatus_, usually in combination with other anaerobes, and its main incidence is on the muscles, which rapidly become infiltrated with gas that spreads throughout the whole extent of the muscle, disintegrating its fibres and leading to necrosis. The gangrenous process spreads with appalling rapidity, the limb becoming enormously swollen, painful, and crepitant or even tympanitic. Patches of coppery or purple colour appear on the skin, and bullae containing blood-stained serum form on the surface. The toxaemia is profound, and the face and lips a.s.sume a characteristic cyanosis. The condition is attended with a high mortality. Only in the early stages and when the infection is limited are local measures successful in arresting the spread; in more severe cases amputation is the only means of saving life.

#Cancrum Oris# or #Noma#.--This disease is believed to be due to a specific bacillus, which occurs in long delicate rods, and is chiefly found at the margin of the gangrenous area. It is p.r.o.ne to attack unhealthy children from two to five years of age, especially during their convalescence from such diseases as measles, scarlet fever, or typhoid, but may attack adults when they are debilitated. It is most common in the mouth, but sometimes occurs on the v.u.l.v.a. In the mouth it begins as an ulcerative stomat.i.tis, more especially affecting the gums or inner aspect of the cheek. The child lies prostrated, and from the open mouth foul-smelling saliva, streaked with blood, escapes; the face is of an ashy-grey colour, the lips dark and swollen. On the inner aspect of the cheek is a deeply ulcerated surface, with sloughy shreds of dark-brown or black tissue covering its base; the edges are irregular, firm, and swollen, and the surrounding mucous membrane is infiltrated and dematous. In the course of a few hours a dark spot appears on the outer aspect of the cheek, and rapidly increases in size; towards the centre it is black, shading off through blue and grey into a dark-red area which extends over the cheek (Fig. 23). The tissue implicated is at first firm and indurated, but as it loses its vitality it becomes doughy and sodden. Finally a slough forms, and, when it separates, the cheek is perforated.

Meanwhile the process spreads inside the mouth, and the gums, the floor of the mouth, or even the jaws, may become gangrenous and the teeth fall out. The const.i.tutional disturbance is severe, the temperature raised, and the pulse feeble and rapid.

The extremely ftid odour which pervades the room or even the house the patient occupies, is usually sufficient to suggest the diagnosis of cancrum oris. The odour must not be mistaken for that due to decomposition of sordes on the teeth and gums of a debilitated patient.

The _prognosis_ is always grave in the extreme, the main risks being general toxaemia and septic pneumonia. When recovery takes place there is serious deformity, and considerable portions of the jaws may be lost by necrosis.

[Ill.u.s.tration: FIG. 23.--Cancrum oris.

(From a photograph lent by Sir George T. Beatson.)]

_Treatment._--The only satisfactory treatment is thorough removal under an anaesthetic of all the sloughy tissue, with the surrounding zone in which the organisms are active. This is most efficiently accomplished by the knife or scissors, cutting until the tissue bleeds freely, after which the raw surface is painted with undiluted carbolic acid and dressed with iodoform gauze. It may be necessary to remove large pieces of bone when the necrotic process has implicated the jaws. The mouth must be constantly sprayed with peroxide of hydrogen, and washed out with a disinfectant and deodorant lotion, such as Condy's fluid. The patient's general condition calls for free stimulation.

The deformity resulting from these necessarily heroic measures is not so great as might be expected, and can be further diminished by plastic operations, which should be undertaken before cicatricial contraction has occurred.

BED-SORES

Bed-sores are most frequently met with in old and debilitated patients, or in those whose tissues are devitalised by acute or chronic diseases a.s.sociated with stagnation of blood in the peripheral veins. Any interference with the nerve-supply of the skin, whether from injury or disease of the central nervous system or of the peripheral nerves, strongly predisposes to the formation of bed-sores. Prolonged and excessive pressure over a bony prominence, especially if the parts be moist with skin secretions, urine, or wound discharges, determines the formation of a sore. Excoriations, which may develop into true bed-sores, sometimes form where two skin surfaces remain constantly apposed, as in the region of the s.c.r.o.t.u.m or labium, under pendulous mammae, or between fingers or toes confined in a splint.

[Ill.u.s.tration: FIG. 24.--Acute Bed-Sores over Right b.u.t.tock.]

_Clinical Features._--Two clinical varieties are met with--the acute and the chronic bed-sore.

The _acute_ bed-sore usually occurs over the sacrum or b.u.t.tock. It develops rapidly after spinal injuries and in the course of certain brain diseases. The part affected becomes red and congested, while the surrounding parts are dematous and swollen, blisters form, and the skin loses its vitality (Fig. 24).

In advanced cases of general paralysis of the insane, a peculiar form of acute bed-sore beginning as a blister, and pa.s.sing on to the formation of a black, dry eschar, which slowly separates, occurs on such parts as the medial side of the knee, the angle of the scapula, and the heel.

The _chronic_ bed-sore begins as a dusky reddish purple patch, which gradually becomes darker till it is almost black. The parts around are dematous, and a blister may form. This bursts and exposes the papillae of the skin, which are of a greenish hue. A tough greyish-black slough forms, and is slowly separated. It is not uncommon for the gangrenous area to continue to spread both in width and in depth till it reaches the periosteum or bone. Bed-sores over the sacrum sometimes implicate the vertebral ca.n.a.l and lead to spinal meningitis, which usually proves fatal.

In old and debilitated patients the septic absorption taking place from a bed-sore often proves a serious complication of other surgical conditions. From this cause, for example, old people may succ.u.mb during the treatment of a fractured thigh.

The granulating surface left on the separation of the slough tends to heal comparatively rapidly.

_Prevention of Bed-sores._--The first essential in the prevention of bed-sores is the regular changing of the patient's position, so that no one part of the body is continuously pressed upon for any length of time. Ring-pads of wool, air-cushions, or water-beds are necessary to remove pressure from prominent parts. Absolute dryness of the skin is all-important. At least once a day, the sacrum, b.u.t.tocks, shoulder-blades, heels, elbows, malleoli, or other parts exposed to pressure, must be sponged with soap and water, thoroughly dried, and then rubbed with methylated spirit, which is allowed to dry on the skin.

Dusting the part with boracic acid powder not only keeps it dry, but prevents the development of bacteria in the skin secretions.

In operation cases, care must be taken that irritating chemicals used to purify the skin do not collect under the patient and remain in contact with the skin of the sacrum and b.u.t.tocks during the time he is on the operating-table. There is reason to believe that the so-called "post-operation bed-sore" may be due to such causes. A similar result has been known to follow soiling of the sheets by the escape of a turpentine enema.

_Treatment._--Once a bed-sore has formed, every effort must be made to prevent its spread. Alcohol is used to cleanse the broken surface, and dry absorbent dressings are applied and frequently changed. It is sometimes found necessary to employ moist or oily substances, such as boracic poultices, eucalyptus ointment, or balsam of Peru, to facilitate the separation of sloughs, or to promote the growth of granulations. In patients who are not extremely debilitated the slough may be excised, the raw surface sc.r.a.ped, and then painted with iodine.

Skin-grafting is sometimes useful in covering in the large raw surface left after separation or removal of sloughs.