Fig. 16.—Bazin's Disease in a girl æt. 16.Fig. 16.—Bazin's Disease in a girl æt. 16.
Fig. 16.—Bazin's Disease in a girl æt. 16.
The condition begins by the formation in the skin and subcutaneous tissue of dusky or livid nodules of induration, which soften and ulcerate, forming small open sores with ragged and undermined edges, not unlike those resulting from the breaking down of superficial syphilitic gummata (Fig. 16). Fresh crops of nodules appear in the neighbourhood of the ulcers, and inturn break down. While in the nodular stage the affection is sometimes painful, but with the formation of the ulcer the pain subsides.
The disease runs a chronic course, and may slowly extend over a wide area in spite of the usual methods of treatment. After lasting for some months, or even years, however, it may eventually undergo spontaneous cure. The most satisfactory treatment is to excise the affected tissues and fill the gap with skin-grafts.
Fig. 17.—Syphilitic Ulcers in region of Knee, showing punched-out appearance and raised indurated edges.Fig. 17.—Syphilitic Ulcers in region of Knee, showing punched-out appearance and raised indurated edges.
Fig. 17.—Syphilitic Ulcers in region of Knee, showing punched-out appearance and raised indurated edges.
Thesyphilitic ulceris usually formed by the breaking down of a cutaneous or subcutaneous gumma in the tertiary stage of syphilis. When the gummatous tissue is first exposed by the destruction of the skin or mucous membrane covering it, it appears as a tough greyish slough, compared to “wash leather,” which slowly separates and leaves a more or less circular, deep, punched-out gap which shows a few feeble unhealthy granulations and small sloughs on its floor. The edges are raised and indurated; and the discharge is thick, glairy, and peculiarly offensive. The parts around the ulcer are congested and of a dark brown colour. There are usually several such ulcers together, and as they tend to heal at one part while they spread at another, the affected area assumes a sinuous or serpiginous outline. Syphilitic ulcers may be met with in any part of the body, but are most frequent in the upper part of the leg (Fig.17), especially around the knee-joint in women, and over the ribs and sternum. On healing, they usually leave a depressed and adherent cicatrix.
Thescorbutic ulceroccurs in patients suffering from scurvy, and is characterised by its prominent granulations, which show a marked tendency to bleed, with the formation of clots, which dry and form a spongy crust on the surface.
Ingoutypatients small ulcers which are exceedingly irritable and painful are liable to occur.
Ulcers associated with Malignant Disease.—Cancer and sarcoma when situated in the subcutaneous tissue may destroy the overlying skin so that the substance of the tumour is exposed. The fungating masses thus produced are sometimes spoken of as malignant ulcers, but as they are essentially different in their nature from all other forms of ulcers, and call for totally different treatment, it is best to consider them along with the tumours with which they are associated. Rodent ulcer, which is one form of cancer of the skin, will be discussed with new growths of the skin.
B.Arrangement of Ulcers according to their Condition.—Having arrived at an opinion as to the cause of a given ulcer, and placed it in one or other of the preceding groups, the next question to ask is, In what condition do I find this ulcer at the present moment?
Any ulcer is in one of three states—healing, stationary, or spreading; although it is not uncommon to find healing going on at one part while the destructive process is extending at another.
The Healing Condition.—The process of healing in an ulcer has already been studied, and we have learned that it takes place by the formation of granulation tissue, which becomes converted into connective tissue, and is covered over by epithelium growing in from the edges.
Those ulcers which arestationary—that is, neither healing nor spreading—may be in one of several conditions.
The Weak Condition.—Any ulcer may get into a weak state from receiving a blood supply which is defective either in quantity or in quality. The granulations are small and smooth, and of a pale yellow or grey colour, the discharge is small in amount, and consists of thin serum and a few pus cells, and as this dries on the edges it forms scabs which interfere with the growth of epithelium.
Should the part become œdematous, either from general causes, such as heart or kidney disease, or from local causes,such as varicose veins, the granulations share in the œdema, and there is an abundant serous discharge.
The excessive use of moist dressings leads to a third variety of weak ulcer—namely, one in which the granulations become large, soft, pale, and flabby, projecting beyond the level of theskin and overlapping the edges, which become pale and sodden. The term “proud flesh” is popularly applied to such redundant granulations.
Fig. 18.—Callous Ulcer, showing thickened edges and indurated swelling of surrounding parts.Fig. 18.—Callous Ulcer, showing thickened edges and indurated swelling of surrounding parts.
Fig. 18.—Callous Ulcer, showing thickened edges and indurated swelling of surrounding parts.
The Callous Condition.—This condition is usually met with in ulcers on the lower third of the leg, and is often associated with the presence of varicose veins. It is chiefly met with in hospital practice. The want of healing is mainly due to impeded venous return and to œdema and induration of the surrounding skin and cellular tissues (Fig. 18). The induration results from coagulation and partial organisation of the inflammatory effusion, and prevents the necessary contraction of the sore. The base of a callous ulcer lies at some distance below the level of the swollen, thickened, and white edges, and presents a glazed appearance, such granulations as are present being unhealthy and irregular. The discharge is usually watery, and cakes in the dressing. When from neglect and want of cleanliness the ulcer becomes inflamed, there is considerable pain, and the discharge is purulent and often offensive.
The prolonged hyperæmia of the tissues in relation to a callous ulcer of the leg often leads to changes in the underlying bones. The periosteum is abnormally thick and vascular, the superficial layers of the bone become injected and porous, and the bones, as a whole, are thickened. In the macerated bone “the surface is covered with irregular, stalactite-like processes or foliaceous masses, which, to a certain extent, follow the line of attachment of the interosseous membrane and of the intermuscular septa” (Cathcart) (Fig. 19). When the whole thickness of the soft tissues is destroyed by the ulcerative process, the area of bone that comes to form the base of the ulcer projects as a flat, porous node, which in its turn may be eroded. These changes as seen in the macerated specimen are often mistaken for disease originating in the bone.
Fig. 19.—Tibia and Fibula, showing changes due to chronic ulcer of leg.Fig. 19.—Tibia and Fibula, showing changes due to chronic ulcer of leg.
Fig. 19.—Tibia and Fibula, showing changes due to chronic ulcer of leg.
Theirritable conditionis met with in ulcers which occur, as a rule, just above the external malleolus in women of neurotic temperament. They are small in size and have prominent granulations, and by the aid of a probe points of excessive tenderness may be discovered. These, Hilton believed, correspond to exposed nerve filaments.
Ulcers which are spreadingmay be met with in one of several conditions.
The Inflamed Condition.—Any ulcer may become acutely inflamed from the access of fresh organisms, aided by mechanical irritation from trauma, ill-fitting splints or bandages, or want of rest, or from chemical irritants, such as strong antiseptics. Thebest clinical example of an inflamed ulcer is the venereal soft sore. The base of the ulcer becomes red and angry-looking, the granulations disappear, and a copious discharge of thin yellow pus, mixed with blood, escapes. Sloughs of granulation tissue or of connective tissue may form. The edges become red, ragged, and everted, and the ulcer increases in size by spreading into the inflamed and œdematous surrounding tissues. Such ulcers are frequently multiple. Pain is a constant symptom, and is often severe, and there is usually some constitutional disturbance.
Thephagedænic conditionis the result of an ulcer being infected with specially virulent bacteria. It occurs in syphilitic ulcers, and rapidly leads to a widespread destruction of tissue. It is also met with in the throat in some cases of scarlet fever, and may give rise to fatal hæmorrhage by ulcerating into large blood vessels. All the local and constitutional signs of a severe septic infection are present.
Treatment of Ulcers.—An ulcer is not only an immediate cause of suffering to the patient, crippling and incapacitating him for his work, but is a distinct and constant menace to his health: the prolonged discharge reduces his strength; the open sore is a possible source of infection by the organisms of suppuration, erysipelas, or other specific diseases; phlebitis, with formation of septic emboli, leading to pyæmia, is liable to occur; and in old persons it is not uncommon for ulcers of long standing to become the seat of cancer. In addition, the offensive odour of many ulcers renders the patient a source of annoyance and discomfort to others. The primary object of treatment in any ulcer is to bring it into the condition of a healing sore. When this has been effected, nature will do the rest, provided extraneous sources of irritation are excluded.
Steps must be taken to facilitate the venous return from theulcerated 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 pharmacopœial 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 scrape 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 constitutional 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.—Theprophylaxisof these ulcers consists inexcluding 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 substituted.Pressure soresare treated on the same lines.
The treatment of ulcers caused byburns and scaldswill be described later.
Inulcers 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 animperfect nerve supplyis 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.
Theperforating ulcerof 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 bismuth or iodoform gauze and encouraged to heal from the bottom. As the parts are insensitive an anæsthetic is not required. After the ulcer has healed, the patient should wear in his boot a thickfelt 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 Constitutional Causes.—When ulcers are associated with such diseases as tuberculosis, syphilis, diabetes, Bright's disease, scurvy, or gout, these must receive appropriate treatment.
The local treatment of thetuberculous ulcercalls 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 Röntgen rays have proved beneficial. The induction of passive hyperæmia, 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 thesyphilitic ulcerdoes to the intra-venous administration of arsenical preparations of the “606” or “914” groups or to full doses of iodide of potassium 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 scraping with the sharp spoon.
Treatment in relation to the Condition of the Ulcer.—Ulcers in a weak condition.—If the weak condition of the ulceris due to anæmia or kidney disease, these affections must first be treated. Locally, the imperfect granulations should be scraped 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 assumed the characters of a healing sore, skin-grafts may be applied to hasten cicatrisation.
Ulcers in a callous conditioncall 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 scraped 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 massage. (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 assumes 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 thewhole 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 circumstances 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 ofelastic 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 recumbent 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 acutelyinflamedas 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.
Thephagedænic ulcercalls 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 theirritable ulcerthe most satisfactory treatment is complete excision and subsequent skin-grafting.
Gangrene or mortification is the process by which a portion of tissue diesen masse, as distinguished from the molecular or cellular death which constitutes ulceration. The dead portion is known as aslough.
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.
Two distinct types of gangrene are met with, which, from their most obvious point of difference, are known respectively asdryandmoist, and there are several clinical varieties of each type.
Speaking generally, it may be said that dry gangrene is essentially due to a simpleinterference with the blood supplyof a part; while the main factor in the production of moist gangrene isbacterial 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 GangreneorMummificationis 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—theline 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 anæmia 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, horny, 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 constitutional 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 Gangreneis 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 bullæ, 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 assume a greenish-black colour from the formation inthem 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.
Theclinical featuresvary in the different varieties of moist gangrene, but the local results of bacterial action and the constitutional disturbance associated with toxin absorption are present in all; the prognosis therefore is grave in the extreme.
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.
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. Moreover, the low state of vitality of the tissues, and the extreme difficulty of securing and maintaining asepsis, make it a sequel of great frequency.
Senile Gangrene.—Senile gangrene is the commonest example of local death produced by agradualdiminution in the quantity of blood passing through the parts, as a result of arterio-sclerosis or other chronic disease of the arteries leading to diminution of their calibre. 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 whohas 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. While it usually attacks only one foot, it is not uncommon for the other foot to be affected after an interval, and in some cases it is bilateral from the outset. It must clearly be understood that any form of gangrene may occur in old persons, the term senile being here restricted to that variety which results from arterio-sclerosis.
Fig. 20.—Senile Gangrene of the Foot, showing line of demarcation.Fig. 20.—Senile Gangrene of the Foot, showing line of demarcation.
Fig. 20.—Senile Gangrene of the Foot, showing line of demarcation.
Clinical Features.—The commonest seat of the disease is in the toes, especially the great toe, whence it spreads up the foot to the heel, or even to the leg (Fig. 20). There is often a history of some slight injury preceding its onset. The vitality of the tissues is so low that the balance between life and death may be turned by the most trivial injury, such as a cut while paring a toe-nail or a corn, a blister caused by an ill-fitting shoe or thecontact of a hot-bottle. In some cases the actual gangrene is determined by thrombosis of the popliteal or tibial arteries, which are already narrowed by obliterating endarteritis.
It is common to find that the patient has been troubled for a long time before the onset of definite signs of gangrene, with cold feet, with tingling and loss of feeling, or a peculiar sensation as if walking on cotton wool.
The first evidence of the death of the part varies in different cases. Sometimes a dark-blue spot appears on the medial side of the great toe and gradually increases in size; or a blister containing blood-stained fluid may form. Streaks or patches of dark-blue mottling appear higher up on the foot or leg. In other cases a small sore surrounded by a congested areola forms in relation to the nail and refuses to heal. Such sores on the toes of old persons are always to be looked upon with suspicion and treated with the greatest care; and the urine should be examined for sugar. There is often severe, deep-seated pain of a neuralgic character, with cramps in the limb, and these may persist long after a line of demarcation has formed. The dying part loses sensibility to touch and becomes cold and shrivelled.
All the physical appearances and clinical symptoms associated with dry gangrene supervene, and the dead portion is delimited by a line of demarcation. If this forms slowly and irregularly it indicates a very unsatisfactory condition of the circulation; while, if it forms quickly and decidedly, the presumption is that the circulation in the parts above is fairly good. The separation of the dead part is always attended with the risk of infection taking place, and should this occur, the temperature rises and other evidences of toxæmia appear.
Prophylaxis.—The toes and feet of old people, the condition of whose circulation predisposes them to gangrene, should be protected from slight injuries such as may be received while paring nails, cutting corns, or wearing ill-fitting boots. The patient should also be warned of the risk of exposure to cold, the use of hot-bottles, and of placing the feet near a fire. Attempts have been made to improve the peripheral circulation by establishing an anastomosis between the main artery of a limb and its companion vein, so that arterial blood may reach the peripheral capillaries—reversal of the circulation—but the clinical results have proved disappointing. (SeeOp. Surg., p. 29.)
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 ofabsorbent 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. Opium should be given freely to alleviate pain. Stimulation is to be avoided, and the patient should be carefully dieted.
When the gangrene is limited to the toes in old and feeble patients, some surgeons advocate the expectant method of treatment, waiting for a line of demarcation to form and allowing the dead part to be separated. This takes place so slowly, however, that it necessitates the patient being laid up for many weeks, or even months; and we agree with the majority in advising early amputation.
In this connection it is worthy of note that there are certain points at which gangrene naturally tends to become arrested—namely, at the highly vascular areas in the neighbourhood of joints. Thus gangrene of the great toe often stops when it reaches the metatarso-phalangeal joint; or if it trespasses this limit it may be arrested either at the tarso-metatarsal or at the ankle joint. If these be passed, it usually spreads up the leg to just below the knee before signs of arrestment appear. Further, it is seen from pathological specimens that the spread is greater on the dorsal than on the plantar aspect, and that the death of skin and subcutaneous tissues extends higher than that of bone and muscle.
These facts furnish us with indications as to the seat and method of amputation. Experience has proved that in senile gangrene of the lower extremity the most reliable and satisfactory results are obtained by amputating in the region of the knee, care being taken to perform the operation so as to leave the prepatellar anastomosis intact by retaining the patella in the anterior flap. The most satisfactory operation in these cases is Gritti's supra-condylar amputation. Hæmorrhage is easily controlled by digital pressure, and the use of a tourniquet should be dispensed with, as the constriction of the limb is liable to interfere with the vitality of the flaps.
When the tibial vessels can be felt pulsating at the ankle it may be justifiable, if the patient urgently desires it, to amputate lower than the knee; but there is considerable risk of gangrene recurring in the stump and necessitating a second operation.
That amputation for senile gangrene performed between the ankle and the knee seldom succeeds, is explained by the fact that the vascular obstruction is usually in the upper part of the posterior tibial artery, and the operation is therefore performed through tissues with an inadequate blood supply. It is not uncommon, indeed, on amputating above the knee, to find even the popliteal artery plugged by a clot. This should be removed at the amputation by squeezing the vessel from above downward by a “milking” movement, or by “catheterising the artery” with the aid of a cannula with a terminal aperture.
It is to be borne in mind that the object of amputation in these cases is merely to remove the gangrenous part, and so relieve the patient of the discomfort and the risks from infection which its presence involves. While it is true that in many of these patients the operation is borne remarkably well, it must be borne in mind that those who suffer from senile gangrene are of necessity bad lives, and a guarded opinion should be expressed as to the prospects of survival. The possibility of the disease developing in the other limb has already been referred to.
Fig. 21.—Embolic Gangrene of Hand and Arm.Fig. 21.—Embolic Gangrene of Hand and Arm.
Fig. 21.—Embolic Gangrene of Hand and Arm.
Embolic Gangrene(Fig. 21).—This is the most typical form of gangrene resulting from thesuddenocclusion of the main artery of a part, whether by the impaction of an embolus or the formation of a thrombus in its lumen, when the collateral circulation is not sufficiently free to maintain the vitality of the tissues.
There is sudden pain at the site of impaction of the embolus, and the pulses beyond are lost. The limb becomes cold, numb, insensitive, and powerless. It is often pale at first—hence the term “white gangrene” sometimes applicable to the early appearances, which closely resemble those presented by the limb of a corpse.
If the part is aseptic it shrivels, and presents the ordinary features of dry gangrene. It is liable, however, especially in the lower extremity and when the veins also are obstructed, to become infected and to assume the characters of the moist type.
The extent of the gangrene depends upon the site of impaction of the embolus, thus if theabdominal aortabecomes 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 theexternal iliacor of thefemoral arteryabove the origin of its deep branch, the death of the limb extends as high as the middle or upper third of the thigh. When thefemoralbelow the origin of its deep branch or thepopliteal arteryis obstructed, the veins remaining pervious, the anastomosis through the profunda is sufficient to maintain the vascular supply, and gangrene does not necessarily follow. The rupture of a popliteal aneurysm, however, by compressing the vein and the articular branches, usually determines gangrene. When an embolus becomes impacted at thebifurcation of the popliteal, if gangrene ensues it usually spreads well up the leg.
When theaxillary arteryis the seat of embolic impaction, and gangrene ensues, the process usually reaches the middle of the upper arm. Gangrene following the blocking of thebrachialat its bifurcation usually extends as far as the junction of the lower and middle thirds of the forearm.
Gangrene due to thrombosis or embolism is sometimes met with in patients recovering from typhus, typhoid, or other fevers, such as that associated with child-bed. It occurs in peripheral parts, such as the toes, fingers, nose, or ears.
Treatment.—The general treatment of embolic gangrene is the same as that for the senile form. Success has followed opening the artery and removing the embolus. The artery is exposed at the seat of impaction and, having been clamped above and below, a longitudinal opening is made and the clot carefully extracted with the aid of forceps; it is sometimes unexpectedly long (one recorded from the femoral artery measured nearly 34 inches); the wound in the artery is then sewn up with fine silk soaked in paraffin. When amputation is indicated, it mustbe performed sufficiently high to ensure a free vascular supply to the flaps.
Gangrene following Ligation of Arteries.—After the ligation of an artery in its continuity—for example, in the treatment of aneurysm—the limb may for some days remain in a condition verging on gangrene, the distal parts being cold, devoid of sensation, and powerless. As the collateral circulation is established, the vitality of the tissues is gradually restored and these symptoms pass off. In some cases, however,—and especially in the lower extremity—gangrene ensues and presents the same characters as those resulting from embolism. It tends to be of the dry type. The occlusion of the vein as well as the artery is not found to increase the risk of gangrene.
Gangrene from Mechanical Constriction of the Vessels of the part.—The application of a bandage or plaster-of-Paris case too tightly, or of a tourniquet for too long a time, has been known to lead to death of the part beyond; but such cases are rare, as are also those due to the pressure of a fractured bone or of a tumour on a large artery or vein. When gangrene occurs from such causes, it tends to be of the moist type.
Much commoner is it to meet with localised areas of necrosis due to the excessivepressure of splintsover bony prominences, such as the lateral malleolus, the medial condyle of the humerus, or femur, or over the dorsum of the foot. This is especially liable to occur when the nutrition of the skin is depressed by any interference with its nerve-supply, such as follows injuries to the spine or peripheral nerves, disease of the brain, or acute anterior poliomyelitis. When the splint is removed the skin pressed upon is found to be of a pale yellow or grey colour, and is surrounded by a ring of hyperæmia. If protected from infection, the clinical course is that of dry gangrene.
Bed-sores, which are closely allied to pressure sores, will be described at the end of this chapter.
When a localised portion of tissue, for example, a piece of skin, is so severelycrushedorbruisedthat its blood vessels are occluded and its structure destroyed, it dies, and, if not infected with bacteria, dries up, and the shrivelled brown skin is slowly separated by the growth of granulation tissue beneath and around it.
Fingers, toes, or even considerable portions of limbs may in the same way be suddenly destroyed by severe trauma, and undergo mummification. If organisms gain access, typical moist gangrene may ensue, or changes similar to those of ordinary post-mortem decomposition may take place.
Treatment.—The first indication is to exclude bacteria by purifying the damaged part and its surroundings, and applying dry, non-irritating dressings.
When these measures are successful, dry gangrene ensues. The raw surface left after the separation of the dead skin may be allowed to heal by granulation, or may be covered by skin-grafts. In the case of a finger or a limb it is not necessary to wait until spontaneous separation takes place, as this is often a slow process. When a well-marked line of demarcation has formed, amputation may be performed just sufficiently far above it to enable suitable flaps to be made.
The end of a stump, after spontaneous separation of the gangrenous portion, requires to be trimmed, sufficient bone being removed to permit of the soft parts coming together.
If moist gangrene supervenes, amputation must be performed without delay, and at a higher level.
Gangrene from Heat, Chemical Agents, and Cold.—Severeburnsandscaldsmay 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.
Strongchemical 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 anæsthetic 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 asTrench feetwas 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 ischæmia 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, œdema, and dusky redness of the foot, and severe pain. According to Paget, the dead partremains 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.
Theprognosiseven 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 toxæmia. 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, anæmia, 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 oflocal syncoperecur 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 hyperæmic and painful.
A more advanced stage of the disease is known aslocal 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 bullæ, and end in dry gangrene. As a rule, the slough whichforms is comparatively small and superficial, but it may take some months to separate. The condition tends to recur in successive winters.
Thetreatmentconsists 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 toangio-sclerosisis 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 passoffwith 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 theclaviceps purpureaand 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 anæsthesia 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.
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 anaërobic bacteria predominate. The anaërobe most constantly present is thebacillus ærogenes capsulatus, usually in association with other anaërobes, 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 œdema 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 œdematous, 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 gangreneis 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, œdematous, and tense. The skin is at first glazed, and perhaps paler than normal, but soon assumes a dull red or purplish hue, and bullæ 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 fromhour 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.