Gangrene

“ It is the most characteristic example of the dry type of gangrene. As the term indicates, it occurs in old persons, but the patient's age is to be reckoned by the condition of his arteries rather than by the number of his years. Thus the vessels of a comparatively young man who has suffered from syphilis and been addicted to alcohol are more liable to atheromatous degeneration leading to this form of gangrene than are those of a much older man who has lived a regular and abstemious life. This form of gangrene is much more common in men than in women. ”

“ In this foul atmosphere amputation did not arrest hospital gangrene, the disease almost invariably returned. Almost every amputation was followed finally by death, either from the effects of gangrene or from the prevailing diarrhea or dysentry. Nitric acid and escharotics generally in this crowded atmosphere, loaded with noxious effluvia, exerted only temporary effects; after their application to the diseased surfaces, the gangrene would frequently return with redoubled energy ”

“ 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 ærogenes capsulatus, usually in combination with other anaërobes, 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. ”

“ When the process of gangrene is checked, the skin immediately beyond the mortified part becomes of a brighter hue, and is affected by a more healthy species of inflammation, which ultimately terminates in ulceration, with purulent discharge, and thereby forms what is called the line of demarcation between the dead and the living parts; the process, commencing in the integuments, gradually extends to the deeply seated parts, so that the mortified portion is ultimately attached to the living merely through the medium of bone or ligament. ”

“ Around the gangrenous mass there is a zone of gray hepatized, friable tissue, which in turn is bounded by a zone of red hepatized tissue. When the above-named zones are not present in diffused gangrene, the cavities are large, and shreds of tissue and vascular bands traverse the cavity, which swarms with bacteria. Such a gangrenous mass may lead to sloughing of the pleuræ. It has been denied that a croupous pneumonia can terminate in gangrene, but modern pathologists all support the opposite view. It may be mentioned that gangrene in croupous pneumonia of the horse is of frequent occurrence. ”

“ Like suppuration, gangrene is associated with and often caused by a bacterial growth. The dead mass remains as an irritant, and is slowly separated by the formation around it of embryonal tissue, granulations and pus. A second form is molecular gangrene, in which the cells and minute elements of the tissue die, and are cast off, leading to phagedenic (eating, extending) sores, as noted above under Ulceration. ”

“ From what has been said, it will be gathered that in dry gangrene there is no urgent call for operation to save the patient's life, the primary indication being to prevent the access of bacteria to the dead part, and especially to the surface exposed at the line of demarcation. In moist gangrene, on the contrary, organisms having already obtained a footing, immediate removal of the dead and dying tissues, as a rule, offers the only hope of saving life. ”

“ Of Internal Gangrene in the lungs, stomach, intestines, kidneys, liver. Pulmonick gangrene from inflammation, is predicted by sudden cessation of pain, without any benign crisis: expectoration either suppressed, or yellow, green, black, and fetid; hollow noise in the breast during respiration; dejected countenance; red and heavy eyes; foul and black tongue; quick, languid, and intermittent pulse; fetid urine, stools, and sweat; hiccup; cold sweats; universal debility and sinking of the vital powers. ”

“ In diabetes, either form may obtain, and a diagnosis can be assured by the discovery of sugar in the urine.
The thickened condition of the arteries leading to senile gangrene must be thought of and proven in aged subjects. Dry gangrene is the rule in arteriosclerosis.
Reynaud’s disease, or synthetic gangrene, is due to a vasomotor spasmodic condition of the terminal vessels and is of central nerve origin. The tips of the toes and fingers, of both sides, are the most common sites, though the lobes of the ears, cheeks and tip of the nose may be affected. ”

“ The gangrene extends often rapidly, in consequence of the infiltration of putrid serosity into the cellular tissue. In the treatment of bruised wounds, the position of the parts must be carefully attended to; they must be placed in a state of relaxation. In general, it is unnecessary to retain the margins of the wound in contact, for adhesion cannot occur—suppuration must ensue, and is to be desired—and the dead and dying parts must be loosened and discharged before union can take place. ”

“ Occasionally the gangrenous cavity becomes chronic and the patient may live for months in imperfect health. The termination of the circumscribed variety is usually death. Diffuse gangrene is invariably fatal.
TREATMENT should be directed, first, to the known precedent states of constitutional weakness, bad habits, etc., which lay a foundation for unhealthy inflammatory processes, and for the pathogenetic elements that bring about the gangrenous and septic and exhausting conditions; second, to the special symptoms, such as severe pain in the side, harassing cough, dyspnoea, etc. ”

“ When gangrene follows the tight application of a ligature, the death of the part seems to depend more on obstruction to the circulation of the blood, than on any diminution of the nervous energy, for we do not observe that paralytic limbs are peculiarly liable to gangrene. The surgeon frequently takes advantage of the fact that a part soon dies when its supply of blood is cut off, or its return in the46 veins interrupted; and has recourse to ligature for removal of parts, When he considers it inexpedient to employ cutting instruments. ”

“ Now, every skillful surgeon protects his patient from these spores, and, binding up the exposed flesh with antiseptic bandages, the wound heals rapidly without secondary symptoms. The existence of inflammatory gangrene in hospitals ought to be forever exorcised.
To religiously prominent men are built shrines, even though they did not perform miracles either during their lives or after death. ”

“ 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. ”

“ An Esthiomenus is a Disposition to Mortification, discover'd by the softness of the Part; and a Gangrene is defin'd to be a Mortification of a Part, occasion'd by the {112}Interception of the Spirits, and the Privation of the Natural Heat.
What are the causes of a Gangrene in general?
Every thing that can hinder the Natural Heat from exerting it self in a Part; as strong Ligatures, astringent or resolvent Medicines, not conveniently us'd in great Inflammations; a violent Hæmorrhage; or Old Age, whereby the Spirits are exhausted ”

“ The extent of the gangrene depends upon the site of impaction of the embolus, thus if the abdominal aorta becomes suddenly occluded by an embolus at its bifurcation, the obstruction of the iliacs and femorals induces symmetrical gangrene of both extremities as high as the inguinal ligaments. When gangrene follows occlusion of the external iliac or of the femoral artery above the origin of its deep branch, the death of the limb extends as high as the middle or upper third of the thigh. ”

“ As a rule, peritonitis soon follows strangulation. The belly becomes tympanitic and tender, the pulse small and wiry, and the face anxious. When gangrene supervenes the pain subsides, the pulse becomes weak and intermittent, the surface cold and clammy, and the patient soon dies in a state of collapse. Slight delirium may precede death, or the mind remain unimpaired to the end. Very often, when gangrene sets in and pain disappears, the patient has a grateful sense of relief and is hopeful of recovery. ”

“ The zone of dulness extends both in a forward and upward direction. The souffle extends forwards. Auscultation and palpation sometimes reveal the formation of an abscess or local gangrene; while there is slight œdema of the wall of the chest, as well as a gurgling sound at the moment when the lung is displaced, high fever, intensely coloured urine, and very marked leucocytosis, etc. Death is inevitable, and when gangrene exists it sometimes occurs suddenly. ”

“ While the varieties of gangrene included in this group depend primarily on interference with the circulation, it is to be borne in mind that the clinical course of the affection may be profoundly influenced by superadded infection with micro-organisms. Although the bacteria do not play the most important part in producing tissue necrosis, their subsequent introduction is an accident of such importance that it may change the whole aspect of affairs and convert a dry form of gangrene into one of the moist type. ”

“ Gangrene of the skin and subjacent tissues has often been traced to the long continued use of dilute solutions of carbolic acid or of ointments containing small quantities of the drug. Gangrene of the fingers and toes is by no means infrequent as a consequence of its use. Another condition frequently seen is the systemic poisoning through absorption. One of the first symptoms noticed from such absorption is irritation of the urinary tract and carboluria. ”

“ This was exquisitely painful, and in the morning, when the drenching was going on, the whole hospital rang with the most agonizing screams.
But the gangrene mostly attacked the legs and arms, and the led more than the arms. Sometimes it killed men inside of a week; sometimes they lingered on indefinitely. I remember one man in the Stockade who cut his hand with the sharp corner of a card of corn bread he was lifting from the ration wagon; gangrene set in immediately, and he died four days after. ”

“ A pre-existing phthisical cavity will take on acute phases, also the septic element will be reinforced, and, as indicated in the enumeration of symptoms, clinical irregularities will be introduced. The early prostration is increased, and the patient dies from exhaustion after a period varying from three days to six weeks from the time the gangrene became manifest. Various complications, such as pleuritis and perforation of pleura and pneumothorax, hemorrhage, or extensive, diffused gangrene may cut short the patient's life within the average period. ”

“ 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. ”

“ The tissues assume a greenish-black colour from the formation in them of a sulphide of iron resulting from decomposition of the blood pigment. Under certain conditions the dead part may undergo changes resembling more closely those of ordinary post-mortem decomposition. Owing to its nature the spread of the gangrene is seldom arrested by the natural protective processes, and it usually continues until the condition proves fatal from the absorption of toxins into the circulation. ”

“ Treatment.—When there is evidence that gangrene has occurred, the first indication is to prevent infection by purifying the part, and after careful drying to wrap it in a thick layer of absorbent and antiseptic wool, retained in place by a loosely applied bandage. A slight degree of elevation of the limb is an advantage, but it must not be sufficient to diminish the amount of blood entering the part. Hot-bottles are to be used with the utmost caution. As absolute dryness is essential, ointments or other greasy dressings are to be avoided, as they tend to prevent evaporation from the skin. ”

“ Hospital No. 2, in which I lay, was inconveniently crowded with severely wounded officers. After my third week, an epidemic of hospital gangrene broke out in my ward. In three days it attacked twenty persons. Then an inspector came out, and we were transferred at once to the open air, and placed in tents. Strangely enough, the wound in my remaining arm, which still suppurated, was seized with gangrene. The usual remedy, bromine, was used locally, but the main artery opened, was tied, bled again and again, and at last, as a final resort, the remaining arm was amputated at the shoulder-joint. ”

“ If the symptoms continue without intermission, and become more violent, a mortification may be apprehended: thus, sudden cessation of pain; low pulse, and great weakness, denote that gangrene has taken place; but, in less urgent cases, where no remarkable changes happen for several days, a more favourable event may be expected; though, when the affection proceeds from injuries in other parts, or the swallowing of poisons, it generally terminates in death. ”