Manual of Surgery Volume I Part 9

Steps must be taken to facilitate the venous return from the ulcerated part, and to ensure that a sufficient supply of fresh, healthy blood reaches it. The septic element must be eliminated by disinfecting the ulcer and its surroundings, and any other sources of irritation must be removed.

If the patient's health is below par, good nourishing food, tonics, and general hygienic treatment are indicated.

_Management of a Healing Sore._--Perhaps the best dressing for a healing sore is a layer of Lister's perforated oiled-silk protective, which is made to cover the raw surface and the skin for about a quarter of an inch beyond the margins of the sore. Over this three or four thicknesses of sterilised gauze, wrung out of eusol, creolin, or sterilised water, are applied, and covered by a pad of absorbent wool. As far as possible the part should be kept at rest, and the position should be adjusted so as to favour the circulation in the affected area.

The dressing may be renewed at intervals, and care must be taken to avoid any rough handling of the sore. Any discharge that lies on the surface should be removed by a gentle stream of lotion rather than by wiping. The area round the sore should be cleansed before the fresh dressing is applied.

In some cases, healing goes on more rapidly under a dressing of weak boracic ointment (one-quarter the strength of the pharmacopial preparation). The growth of epithelium may be stimulated by a 6 to 8 per cent. ointment of scarlet-red.

Dusting powders and poultice dressings are best avoided in the treatment of healing sores.

In extensive ulcers resulting from recent burns, if the granulations are healthy and aseptic, skin-grafts may safely be placed on them directly.

If, however, their asepticity cannot be relied upon, it is necessary to sc.r.a.pe away the superficial layer of the granulations, the young fibrous tissue underneath being conserved, as it is sufficiently vascular to nourish the grafts placed on it.

#Treatment of Special Varieties of Ulcers.#--Before beginning to treat a given ulcer, two questions have to be answered--first, What are the causative conditions present? and second, In what condition do I find the ulcer?--in other words, In what particulars does it differ from a healthy healing sore?

If the cause is a local one, it must be removed; if a const.i.tutional one, means must be taken to counteract it. This done, the condition of the ulcer must be so modified as to bring it into the state of a healing sore, after which it will be managed on the lines already laid down.

#Treatment in relation to the Cause of the Ulcer.#--_Traumatic Group._--The _prophylaxis_ of these ulcers consists in excluding bacteria, by cleansing crushed or bruised parts, and applying sterilised dressings and properly adjusted splints. If there is reason to fear that the disinfection has not been complete, a Bier's constricting bandage should be applied for some hours each day. These measures will often prevent a grossly injured portion of skin dying, and will ensure asepticity should it do so. In the event of the skin giving way, the same form of dressing should be continued till the slough has separated and a healthy granulating surface is formed. The protective dressing appropriate to a healing sore is then subst.i.tuted. _Pressure sores_ are treated on the same lines.

The treatment of ulcers caused by _burns and scalds_ will be described later.

In _ulcers of the leg due to interference with the venous return_, the primary indication is to elevate the limb in order to facilitate the flow of the blood in the veins, and so admit of fresh blood reaching the part. The limb may be placed on pillows, or the foot of the bed raised on blocks, so that the ulcer lies on a higher level than the heart.

Should varicose veins be present, the question of operative treatment must be considered.

When an _imperfect nerve supply_ is the main factor underlying ulcer formation, prophylaxis is the chief consideration. In patients suffering from spinal injuries or diseases, cerebral paralysis, or affections of the peripheral nerves, all sources of irritation, such as ill-fitting splints, tight bandages, moist applications, and hot bottles, should be avoided. Any part liable to pressure, from the position of the patient or otherwise, must be carefully protected by pads of wool, air-cushions, or water-bags, and must be kept absolutely dry. The skin should be hardened by daily applications of methylated spirit.

Should an ulcer form in spite of these precautions, the mildest antiseptics must be employed for bathing and dressing it, and as far as possible all dressings should be dry.

The _perforating ulcer_ of the foot calls for special treatment. To avoid pressure on the sole of the foot, the patient must be confined to bed. As the main local obstacle to healing is the down-growth of epithelium along the sides of the ulcer, this must be removed by the knife or sharp spoon. The base also should be excised, and any bone which may have become involved should be gouged away, so as to leave a healthy and vascular surface. The cavity thus formed is stuffed with bis.m.u.th or iodoform gauze and encouraged to heal from the bottom. As the parts are insensitive an anaesthetic is not required. After the ulcer has healed, the patient should wear in his boot a thick felt sole with a hole cut out opposite the situation of the cicatrix. When a joint has been opened into, the difficulty of thoroughly getting rid of all unhealthy and infected granulations is so great that amputation may be advisable, but it is to be remembered that ulceration may recur in the stump if pressure is put upon it. The treatment of any nervous disease or glycosuria which may coexist is, of course, indicated.

Exposure of the plantar nerves by an incision behind the medial malleolus, and subjecting them to forcible stretching, has been employed by Chipault and others in the treatment of perforating ulcers of the foot.

The ulcer that forms in relation to callosities on the sole of the foot is treated by paring away all the thickened skin, after softening it with soda fomentations, removing the unhealthy granulations, and applying stimulating dressings.

_Treatment of Ulcers due to Const.i.tutional Causes._--When ulcers are a.s.sociated with such diseases as tuberculosis, syphilis, diabetes, Bright's disease, scurvy, or gout, these must receive appropriate treatment.

The local treatment of the _tuberculous ulcer_ calls for special mention. If the ulcer is of limited extent and situated on an exposed part of the body, the most satisfactory method is complete removal, by means of the knife, scissors, or sharp spoon, of the ulcerated surface and of all the infected area around it, so as to leave a healthy surface from which granulations may spring up. Should the raw surface left be likely to result in an unsightly scar or in cicatricial contraction, skin-grafting should be employed.

For extensive ulcers on the limbs, the chest wall, or on other covered parts, or when operative treatment is contra-indicated, the use of tuberculin and exposure to the Rontgen rays have proved beneficial. The induction of pa.s.sive hyperaemia, by Bier's or by Klapp's apparatus, should also be used, either alone or supplementary to other measures.

No ulcerative process responds so readily to medicinal treatment as the _syphilitic ulcer_ does to the intra-venous administration of a.r.s.enical preparations of the "606" or "914" groups or to full doses of iodide of pota.s.sium and mercury, and the local application of black wash. When the ulceration has lasted for a long time, however, and is widespread and deep, the duration of treatment is materially shortened by a thorough sc.r.a.ping with the sharp spoon.

#Treatment in relation to the Condition of the Ulcer.#--_Ulcers in a weak condition._--If the weak condition of the ulcer is due to anaemia or kidney disease, these affections must first be treated. Locally, the imperfect granulations should be sc.r.a.ped away, and some stimulating agent applied to the raw surface to promote the growth of healthy granulations. For this purpose the sore may be covered with gauze smeared with a 6 to 8 per cent. ointment of scarlet-red, the surrounding parts being protected from the irritant action of the scarlet-red by a layer of vaseline. A dressing of gauze moistened with eusol or of boracic lint wrung out of red lotion (2 grains of sulphate of zinc, and 10 minims of compound tincture of lavender, to an ounce of water), and covered with a layer of gutta-percha tissue, is also useful.

When the condition has resulted from the prolonged use of moist dressings, these must be stopped, the redundant granulations clipped away with scissors, the surface rubbed with silver nitrate or sulphate of copper (blue-stone), and dry dressings applied.

When the ulcer has a.s.sumed the characters of a healing sore, skin-grafts may be applied to hasten cicatrisation.

_Ulcers in a callous condition_ call for treatment in three directions--(1) The infective element must be eliminated. When the ulcer is foul, relays of charcoal poultices (three parts of linseed meal to one of charcoal), maintained for thirty-six to forty-eight hours, are useful as a preliminary step. The base of the ulcer and the thickened edges should then be freely sc.r.a.ped with a sharp spoon, and the resulting raw surface sponged over with undiluted carbolic acid or iodine, after which an antiseptic dressing is applied, and changed daily till healthy granulations appear. (2) The venous return must be facilitated by elevation of the limb and ma.s.sage. (3) The induration of the surrounding parts must be got rid of before contraction of the sore is possible. For this purpose the free application of blisters, as first recommended by Syme, leaves little to be desired. Liquor epispasticus painted over the parts, or a large fly-blister (emplastrum cantharidis) applied all round the ulcer, speedily disperses the inflammatory products which cause the induration. The use of elastic pressure or of strapping, of hot-air baths, or the making of multiple incisions in the skin around the ulcer, fulfils the same object.

As soon as the ulcer a.s.sumes the characters of a healing sore, it should be covered with skin-grafts, which furnish a much better cicatrix than that which forms when the ulcer is allowed to heal without such aid.

A more radical method of treatment consists in excising the whole ulcer, including its edges and about a quarter of an inch of the surrounding tissue, as well as the underlying fibrous tissue, and grafting the raw surface.

_Ambulatory Treatment._--When the circ.u.mstances of the patient forbid his lying up in bed, the healing of the ulcer is much delayed. He should be instructed to take every possible opportunity of placing the limb in an elevated position, and must constantly wear a firm bandage of _elastic webbing_. This webbing is porous and admits of evaporation of the skin and wound secretions--an advantage it has over Martin's rubber bandage. The bandage should extend from the toes to well above the knee, and should always be applied while the patient is in the rec.u.mbent position with the leg elevated, preferably before getting out of bed in the morning. Additional support is given to the veins if the bandage is applied as a figure of eight.

We have found the following method satisfactory in out-patient practice. The patient lying on a couch, the limb is raised about eighteen inches and kept in this position for five minutes--till the excess of blood has left it. With the limb still raised, the ulcer with the surrounding skin is covered with a layer, about half an inch thick, of finely powdered boracic acid, and the leg, from foot to knee, excluding the sole, is enveloped in a thick layer of wood-wool wadding.

This is held in position by ordinary cotton bandages, painted over with liquid starch; while the starch is drying the limb is kept elevated.

With this appliance the patient may continue to work, and the dressing does not require to be changed oftener than once in three or four weeks (W. G. Richardson).

When an ulcer becomes acutely _inflamed_ as a result of superadded infection, antiseptic measures are employed to overcome the infection, and ichthyol or other soothing applications may be used to allay the pain.

The _phagedaenic ulcer_ calls for more energetic means of disinfection; the whole of the affected surface is touched with the actual cautery at a white heat, or is painted with pure carbolic acid. Relays of charcoal poultices are then applied until the spread of the disease is arrested.

For the _irritable ulcer_ the most satisfactory treatment is complete excision and subsequent skin-grafting.

CHAPTER VI

GANGRENE

Definition--Types: _Dry_, _Moist_--Varieties--Gangrene primarily due to interference with circulation: _Senile gangrene_; _Embolic gangrene_; _Gangrene following ligation of arteries_; _Gangrene from mechanical causes_; _Gangrene from heat, chemical agents, and cold_; _Diabetic gangrene_; _Gangrene a.s.sociated with spasm of blood vessels_; _Raynaud's disease_; _Angio-sclerotic gangrene_; _Gangrene from ergot_. Bacterial varieties of gangrene.

_Pathology_--clinical varieties--_Acute infective gangrene_; _Malignant dema_; _Acute emphysematous_ or _gas gangrene_; _Cancrum oris_, _etc_. Bed-sores: _Acute_; _chronic_.

Gangrene or mortification is the process by which a portion of tissue dies _en ma.s.se_, as distinguished from the molecular or cellular death which const.i.tutes ulceration. The dead portion is known as a _slough_.

In this chapter we shall confine our attention to the process as it affects the limbs and superficial parts, leaving gangrene of the viscera to be described in regional surgery.

TYPES OF GANGRENE

Two distinct types of gangrene are met with, which, from their most obvious point of difference, are known respectively as _dry_ and _moist_, and there are several clinical varieties of each type.

Speaking generally, it may be said that dry gangrene is essentially due to a simple _interference with the blood supply_ of a part; while the main factor in the production of moist gangrene is _bacterial infection_.

The cardinal signs of gangrene are: change in the colour of the part, coldness, loss of sensation and motor power, and, lastly, loss of pulsation in the arteries.

#Dry Gangrene# or #Mummification# is a comparatively slow form of local death due, as a rule, to a diminution in the arterial blood supply of the affected part, resulting from such causes as the gradual narrowing of the lumen of the arteries by disease of their coats, or the blocking of the main vessel by an embolus.

As the fluids in the tissues are lost by evaporation the part becomes dry and shrivelled, and as the skin is usually intact, infection does not take place, or if it does, the want of moisture renders the part an unsuitable soil, and the organisms do not readily find a footing. Any spread of the process that may take place is chiefly influenced by the anatomical distribution of the blocked arteries, and is arrested as soon as it reaches an area rich in anastomotic vessels. The dead portion is then cast off, the irritation resulting from the contact of the dead with the still living tissue inducing the formation of granulations on the proximal side of the junction, and these by slowly eating into the dead portion produce a furrow--the _line of demarcation_--which gradually deepens until complete separation is effected. As the muscles and bones have a richer blood supply than the integument, the death of skin and subcutaneous tissues extends higher than that of muscles and bone, with the result that the stump left after spontaneous separation is conical, the end of the bone projecting beyond the soft parts.

_Clinical Features._--The part undergoing mortification becomes colder than normal, the temperature falling to that of the surrounding atmosphere. In many instances, but not in all, the onset of the process is accompanied by severe neuralgic pain in the part, probably due to anaemia of the nerves, to neuritis, or to the irritation of the exposed axis cylinders by the dead and dying tissues around them. This pain soon ceases and gives place to a complete loss of sensation. The dead part becomes dry, h.o.r.n.y, shrivelled, and semi-transparent--at first of a dark brown, but finally of a black colour, from the dissemination of blood pigment throughout the tissues. There is no putrefaction, and therefore no putrid odour; and the condition being non-infective, there is not necessarily any const.i.tutional disturbance. In itself, therefore, dry gangrene does not involve immediate risk to life; the danger lies in the fact that the breach of surface at the line of demarcation furnishes a possible means of entrance for bacteria, which may lead to infective complications.

#Moist Gangrene# is an acute process, the dead part retaining its fluids and so affording a favourable soil for the development of bacteria. The action of the organisms and their toxins on the adjacent tissues leads to a rapid and wide spread of the process. The skin becomes moist and macerated, and bullae, containing dark-coloured fluid or gases, form under the epidermis. The putrefactive gases evolved cause the skin to become emphysematous and crepitant and produce an offensive odour. The tissues a.s.sume a greenish-black colour from the formation in them of a sulphide of iron resulting from decomposition of the blood pigment.