The principles and practice of modern surgery

by Roswell Park

There are also forms of visceral gangrene, traumatic and non-traumatic, which often constitute fatal maladies. The latter are mainly due to thrombotic or embolic lesions, for example, the gangrene of the mesentery, already alluded to when discussing [thrombosis] (q. v.), clinically described under Surgical Diseases of the Mesentery.

Gross Appearances.

—In a general way tissue death, known as gangrene, assumes two opposite types—the moist and the dry. In moist gangrene, aside from those appearances which indicate commencing putrefaction of tissues, and the loss of heat due to stoppage of the blood supply, one of the most characteristic features is the formation of a so-called line of demarcation, i. e., a line which separates the dead from the living tissues. While this is usually plainly indicated by a red line which abruptly separates the discolored, usually dark, dead portion from the bright red, congested appearance of the living tissues, it is noted that this area of redness shades out into a more and more natural appearance as we pass upward, while below the line is seen a surface, usually covered with blisters, from which exudes a foul-smelling, altered serum, while the gangrenous portion assumes a dark, finally an almost black appearance, retaining only the crude outlines of its original shape. Along with this the objective evidences of putrefaction are unmistakable, appearances and odor being characteristic. With all there are more or less constitutional disturbances, and a recognizable, often a profound, condition of septic infection, due to the fact that along the line of demarcation absorbents are still active and that the poisonous products of putrefaction are being absorbed into the general system. Consequently collapse, profuse perspiration, septic diarrhea, etc., are noted. In gangrene from frostbite the process is slower than in the traumatic forms. In gangrene from extravasation of urine the separation of sloughs is extensive, and sloughing of the scrotum with exposure of the testicles is a frequent result. In decubitus, or bed-sore, the process is still more slow, but always of the moist type. After a variable length of time there is separation of slough and a resulting large, often foul, ulcer.

Dry or senile gangrene presents a very distinct contrast to the moist type. It occurs generally in patients over fifty, often as the result of causes which are slow of action. As a result of the shrinking and corrugation of the tissues, with the dryness of the same by evaporation, there is a peculiar appearance known as mummification, the foot, for instance—the feet are usually first involved—resembling the foot of a person who has been embalmed, except that it is discolored. It is possible sometimes to have a combination of moist and senile gangrene, especially when there has been infection by which putrefaction is permitted. When from the outset putrefactive processes are prevented, the gangrene of this type is almost invariably dry. In practically all of the cases of this character there will be found evidences of vascular disease, usually in the femoral artery and its branches. Gangrene of the foot alone is most commonly due to endarteritis, while gangrene of the foot and leg together are usually due to embolism or thrombosis.

While disease of the vessel walls is usually of the type either of endarteritis or arterial sclerosis, peculiar to the closing years of life, and commonly affecting the lower extremities, gangrene due to embolism of arteries or thrombosis, or both, may occur in the young, and in the upper extremities as well, in the latter case the emboli being detached from the heart, while thrombosis may be caused by a tight splint or bandage, or even the use of crutches. I have repeatedly amputated the arm as well as the leg for gangrene of this type.

Signs and Symptoms.

—The appearance and the odor of a part will indicate impending or actual traumatic gangrene. The pallor, the coldness, the dryness of senile gangrene are also characteristic. In the latter form constitutional symptoms are not indicative nor essentially of septic type. As soon, however, as a process of spontaneous separation begins putrefaction is inevitable and sepsis unavoidable. In moist gangrene there is seldom acute pain. This is one of the predominating subjective features of the senile form. Hemorrhages occur, sometimes terminating fatally, in the moist forms when large vessels are eroded. This is particularly true of the phagedenic or hospital form. A recognition of their possibility may enable us to avoid sudden death from this source.

Treatment.

—Threatening gangrene should be attacked and the cause removed. Threatening bed-sores may be avoided by equalizing surface pressure, which can be done with the water-bed; by protecting the skin or by stimulating and toughening it with alcoholic and astringent lotions; by frequent changes of position; by attention to the heart, which should be stimulated to a point that may make it capable of forcing or distributing blood equally over the entire body. So, too, with limbs which are enveloped in dressings or splints; it is well to leave exposed the tips of the toes or fingers in order that discoloration of the same may be recognized and the threatening disasters averted. Local gangrene as the result of pressure by tumors, aneurysms, etc., cannot always be averted.

For gangrene there is but one relief, the removal of the dead and dying tissue. The method and location of the operation must be determined by the general character of the cause. For a case of acute traumatic gangrene amputation at the nearest point of election above the injury will often suffice. In case of gangrene from frostbite the tissues in the neighborhood of the line of demarcation are so affected or their vitality so compromised that to separate the tissues along the lines at which nature is endeavoring to remove them is not enough, and to go an inch or so above this line is to operate in tissues which bleed readily and heal badly. Consequently it is often advisable to select a point at some distance above. It is especially in diabetic and senile gangrene that surgeons have laid down the rule that if amputation is done at all it must be high. For gangrene of the toe, as the result of disease of the vessels, it is best to amputate above the ankle; whereas if any greater portion of the foot is threatened, amputation should take place above the knee. The tibial arteries have been found so brittle as to snap under a ligature, and the femorals so disorganized as to require handling and ligating with the greatest caution. These high amputations are therefore necessitated by the condition of the vessel walls. While amputation for traumatic and acute cases is, in the majority of instances, if not too long delayed, successful in saving life, in the senile and particularly in the diabetic forms it is, in the majority of cases, a disappointment.