Alexis Thomson and Alexander Miles - Manual of Surgery

A >> Alexis Thomson and Alexander Miles >> Manual of Surgery

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If moist gangrene supervenes, amputation must be performed without
delay, and at a higher level.

#Gangrene from Heat, Chemical Agents, and Cold.#--Severe #burns# and
#scalds# may be followed by necrosis of tissue. So long as the parts are
kept absolutely dry--as, for example, by the picric acid method of
treatment--the grossly damaged portions of tissue undergo dry gangrene;
but when wet or oily dressings are applied and organisms gain access,
moist gangrene follows.

Strong #chemical agents#, such as caustic potash, nitric or sulphuric
acid, may also induce local tissue necrosis, the general appearances of
the lesions produced being like those of severe burns. The resulting
sloughs are slow to separate, and leave deep punched-out cavities which
are long of healing.

#Carbolic Gangrene.#--Carbolic acid, even in comparatively weak
solution, is liable to induce dry gangrene when applied as a fomentation
to a finger, especially in women and children. Thrombosis occurs in the
blood vessels of the part, which at first is pale and soft, but later
becomes dark and leathery. On account of the anaesthetic action of
carbolic acid, the onset of the process is painless, and the patient
does not realise his danger. A line of demarcation soon forms, but the
dead part separates very slowly.

#Gangrene from Frost-bite.#--It is difficult to draw the line between
the third degree of chilblain and the milder forms of true frost-bite;
the difference is merely one of degree. Frost-bite affects chiefly the
toes and fingers--especially the great toe and the little finger--the
ears, and the nose. In this country it is seldom seen except in members
of the tramp class, who, in addition to being exposed to cold by
sleeping in the open air, are ill-fed and generally debilitated. The
condition usually manifests itself after the parts, having been
subjected to extreme cold, are brought into warm surroundings. The first
symptom is numbness in the part, followed by a sense of weight,
tingling, and finally by complete loss of sensation. The part attacked
becomes white and bleached-looking, feels icy cold, and is insensitive
to touch. Either immediately, or, it may be, not for several days, it
becomes discoloured and swollen, and finally contracts and shrivels.
Above the dead area the limb may be the seat of excruciating pain. The
dead portion is cast off, as in other forms of dry gangrene, by the
formation of a line of demarcation.

To prevent the occurrence of gangrene from frost-bite it is necessary to
avoid the sudden application of heat. The patient should be placed in a
cold room, and the part rubbed with snow, or put in a cold bath, and
have light friction applied to it. As the circulation is restored the
general surroundings and the local applications are gradually made
warmer. Elevation of the part, wrapping it in cotton wool, and removal
to a warmer room, are then permissible, and stimulants and warm drinks
may be given with caution. When by these means the occurrence of
gangrene is averted, recovery ensues, its onset being indicated by the
white parts assuming a livid red hue and becoming the seat of an acute
burning sensation.

A condition known as _Trench feet_ was widely prevalent amongst the
troops in France during the European War. Although allied to frost-bite,
cold appears to play a less important part in its causation than
humidity and constriction of the limbs producing ischaemia of the feet.
Changes were found in the endothelium of the blood vessels, the axis
cylinders of nerves, and the muscles. The condition does not occur in
civil life.

#Diabetic Gangrene.#--This form of gangrene is prone 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 associated 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, assumes the dry, shrivelling
type, as a rule being attended with swelling, oedema, 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 assumes 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 succumb 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 associated 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 pass 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 assume a dull, livid hue. There is swelling and burning or
shooting pain. This may pass 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 passed. 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 analogies 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 pass 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 quantities of coarse 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 assume 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 association with other anaerobes, and
sometimes with pyogenic diplo- and streptococci. According to the mode of
action of the associated 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 oedema 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 oedematous, 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-prick 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, oedematous, and tense. The skin is at first glazed, and perhaps
paler than normal, but soon assumes 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.

[Illustration: 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 quantity 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 assistant 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 Oedema.#--This form of acute gangrene has been defined as
"a spreading inflammatory oedema attended with emphysema, and ultimately
followed by gangrene of the skin and adjacent parts." The predominant
organism is the _bacillus of malignant oedema_ 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 oedema, however, the
incidence of the disease is mainly on the superficial parts, which
become oedematous 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 constitutional 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 assume 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 prone 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 vulva. In the mouth it
begins as an ulcerative stomatitis, 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 oedematous. 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 constitutional disturbance is severe, the temperature raised,
and the pulse feeble and rapid.

The extremely foetid 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.

[Illustration: 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
associated 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 scrotum or labium, under pendulous
mammae, or between fingers or toes confined in a splint.

[Illustration: FIG. 24.--Acute Bed-Sores over Right Buttock.]

_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 buttock. 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 oedematous 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 passing 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
oedematous, 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 canal 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 succumb 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, buttocks,
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 buttocks 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 scraped, and then painted with iodine.

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

CHAPTER VII

BACTERIAL AND OTHER WOUND INFECTIONS

_Erysipelas_--_Diphtheria_--_Tetanus_--_Hydrophobia_--_Anthrax_--
_Glanders_--_Actinomycosis_--_Mycetoma_--_Delhi
boil_--_Chigoe_--_Poisoning by insects_--_Snake-bites_.

ERYSIPELAS

Erysipelas, popularly known as "rose," is an acute spreading infective
disease of the skin or of a mucous membrane due to the action of a
streptococcus. Infection invariably takes place through an abrasion of
the surface, although this may be so slight that it escapes observation
even when sought for. The streptococci are found most abundantly in the
lymph spaces just beyond the swollen margin of the inflammatory area,
and in the serous blebs which sometimes form on the surface.

#Clinical Features.#--_Facial erysipelas_ is the commonest clinical
variety, infection usually occurring through some slight abrasion in the
region of the mouth or nose, or from an operation wound in this area.
From this point of origin the inflammation may spread all over the face
and scalp as far back as the nape of the neck. It stops, however, at the
chin, and never extends on to the front of the neck. There is great
oedema of the face, the eyes becoming closed up, and the features
unrecognisable. The inflammation may spread to the meninges, the
intracranial venous sinuses, the eye, or the ear. In some cases the
erysipelas invades the mucous membrane of the mouth, and spreads to the
fauces and larynx, setting up an oedema of the glottis which may prove
dangerous to life.