CHAPTER V

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GANGRENE.

Gangrene is known also as _necrosis_, although this term is usually limited to gangrene of bone. It is known also as _mortification_, and to the older writers, especially when soft parts die and separate in sloughs, as _sphacelus_. _Gangrene means death of tissue in visible and more or less circumscribed masses._ It is distinguished from ulceration not on account of molecular disintegration, particle by particle, but because of death _in toto and synchronously_ of a large, perhaps innumerable, number of cells. Gangrene is described as due to causes which may be:

A. =Traumatic=, including the so-called thermal causes as essentially mechanical injuries. Under this head are included cases where _injury_ is the primary cause, whether this injury is the crushing of a limb, the separation or occlusion of its main bloodvessels, the division of its main nerves, or the crushing or pulpefying of its entire structure by machinery or accident; also those so-called _thermal_ cases which are due to intense heat or intense cold. To these might be added the _chemical_ causes, comprising injuries by powerful caustics, alkalies, or acids, which are known to cause speedy death of every living tissue with which they come in contact.

Gangrene from _frostbite_ is often of the moist type. There is scarcely a limit to its extent, either in area or depth. It is due primarily to thrombosis, which is followed by a purplish color of the skin, by loss of local warmth, and numbness. Naturally it involves the ears, nose, fingers, and toes. But after alcoholism and exposure one or more entire limbs may be involved. With moist gangrene there is danger of septic infection (_q. v._). After formation of a line of demarcation the line of amputation may be made to follow it closely, but the best results are obtained by higher division, at points of election, where tissues are less sensitive and less infiltrated.

B. =Local Causes.=--These are largely connected with _ischemia_. _Gangrene from edema_--itself the result of passive hyperemia and exudation--is not infrequent, the most common expression of this condition being seen perhaps in the external genitals of the male. _Embolism_ due to valvular heart disease, _thrombosis_ due usually to a preceding phlebitis, but possibly to marasmic origin, especially met with after confinement, with disturbance in the uterine sinuses, shutting off the circulation by endarteritis, which thus assumes the form _obliterans_, are some of the local causes which concern the bloodvessels alone. In fact, the majority of cases of spontaneous gangrene are probably due to changes in the vessels, endarteritis being the cause of a condition known as atheroma of vessels, in which fungoid outgrowths, or, rather, ingrowths into the vessel lumen, are common. Any one of these, if detached, may serve as an embolus. The degenerative excavations in the thickened walls of the bloodvessels, which discharge more or less cholesterin and other debris, and which have been known as _atheromatous abscesses_ (misnomer), are frequently the precursors of the disease under consideration. As the result of these changes alone, without reference to formation of emboli, vessels may become completely occluded, especially when slightly injured.[2]

[2] Intermittent claudication, when recognized, may be regarded as a precursor of that arteriosclerosis which may proceed to gangrene. The term implies temporary anemia of one or more of the extremities, with numbness, burning, or prickling sensations in the skin, occasional cramps in the muscles, with loss of power, tenderness of the nerve trunks, weakening or loss of pulse in the affected part. When these symptoms occur in the feet they are not infrequently followed by terminal gangrene or other evidences of angioneurotic necrosis, including even those forms known as erythromelalgia and Raynaud’s disease. Its treatment, of course, is relaxation of vasomotor spasm, best accomplished by the use of the nitrites, among which nitroglycerin is perhaps most valuable.

_Extravasation_ of blood is another cause connected with the bloodvessels, this coming usually from traumatic rupture, possibly from idiopathic causes. At any rate, the tension in the part may threaten its life because of the pressure which overcomes the circulation of blood. _Ligation_ of the main trunk of an artery is sometimes followed by gangrene, no matter how carefully done, collateral circulation being insufficient to sustain the nourishment of the part. In certain fractures, simple as well as compound, the blood supply of a part is rudely broken off by injury to a bloodvessel in such a way as to cause local or general death, either of a bone or of the entire limb. Flaps made for plastic purposes, arranged without sufficient regard to their proper blood supply, or so dressed after operation as to sustain undue pressure, are often so shut off from the heart as to die for want of blood. Finally, gangrene may be the result of _pressure_ either from splints, bandages, etc., or from _tumors_ increasing in size, or possibly, as in certain pressure sores, etc., from the mere weight of the body. Here, too, _chemical agents_ must be mentioned, referring now to the peculiar action of certain _foods or drugs_, particularly ergot. Thus antiseptic solutions, particularly carbolic acid, may be made strong enough to destroy the vitality of certain tissues. Carbolic gangrene (Warren) is a possibility not to be forgotten.

Extravasation of urine, unless promptly recognized and appropriately treated, or especially as occurring when the urine is peculiarly toxic (ammoniacal) and the patient’s vitality reduced, as in confirmed alcoholics, is almost sure to produce gangrene which may easily terminate fatally.

[Illustration: FIG. 14

Raynaud’s disease: digiti mortui. (Original.)]

[Illustration: FIG. 15

Raynaud’s disease: perforating ulcer of foot. (Original.)]

C. =Constitutional Causes.=--Among these are to be mentioned

## particularly that symptom-complex ordinarily known as _diabetes_ or

_glycosuria_. This means a depraved condition of the system in which gangrene is threatened or permitted under circumstances which otherwise would have little or no disastrous effect. Thus _diabetic gangrene_ has come to be one of the recognized manifestations of the general disease. That the trophic nerves have a more or less pronounced effect in determining gangrene in certain cases seems to be now quite well established. It is well known how quickly _bed-sores_ form after injuries to the spine, while in certain nervous affections a minimum of friction of the skin may determine its death, particularly about the labia or scrotum. It is said that the insane, when made to sleep by chloral, may develop decubitus from pressure in a single night. There is also a well-known form of _symmetrical gangrene_, known sometimes as _Raynaud’s disease_, which is characterized by symmetry of lesions and absence of definite pathological changes (Figs. 14 and 15). The so-called _digiti mortui_, or _dead fingers_, and _erythromelalgia_ are examples of this character. A condition almost leading up to gangrene, but perhaps not absolutely terminating in such a way, has been known as _local asphyxia_, which seems to be a condition of arterial spasm with venous congestion and slight edema. While the aged will often recover from a legitimate surgical operation without disturbance, it is, nevertheless, true that senile gangrene commencing in the toes has for its cause some very trifling injury or lesion, such, _e. g._, as paring of a corn, or the like. This shows a weakened local and general resistance, as well as the wisdom of redoubling aseptic precautions in operations upon such patients.

As constitutional causes also should be included the deleterious effects of certain drugs, particularly ergot, mercury, and phosphorus.

D. =Infectious Causes.=--In the instances already mentioned reference to the infectious microörganisms has been avoided. There remain to be considered types of gangrene due to the activity of certain microörganisms--_hospital gangrene_, _phlegmonous erysipelas_, _malignant edema_, _gangrenous emphysema_, _noma_, _ainhum_, etc.

Gangrene as the result of infectious processes is seen in phlegmonous erysipelas, where death of tissue seems to be due to the combined influence of the invading organisms and of mechanical agencies--_i. e._, tension produced by stasis and exudation, with such stretching of tissues or overcrowding with inflammatory products as to virtually strangle them, in consequence of all of which they die. Gangrene of an entire hand may thus result, or, more commonly, the gangrene is limited in extent to the more superficial parts, so that sloughs separate. A specific form of gangrenous inflammation known as _malignant edema_, due to a peculiar anaërobic bacillus, will be treated of separately under a distinct heading. Quite like it in several respects is the gangrenous emphysema of certain writers, known also as the fulminating form, or, as the French call it, the “_gangrène foudroyante_.” More or less emphysematous condition may accompany malignant edema; yet that we do have gaseous forms of gangrene without the specific bacillus of malignant edema is established. At least sixteen cases of so-called gaseous gangrene due to infection by the _bacillus aërogenes capsulatus_ are on record, of which twelve were fatal. Most of them followed surgical injuries--_e. g._, compound fracture.

[Illustration: FIG. 16

Noma. (Original.)]

_Hospital gangrene_, so called, has been in years past the terror of military surgeons and camp hospitals. As a type it has almost completely disappeared from observation, and, in its old manifestations at least, is now practically never seen.

_Noma_, known also as _gangrenous stomatitis_, _cancrum oris_, and _gangræna oris_, is a term applied to a form of tissue necrosis affecting the cheeks or parts about the face of young children, occurring frequently as a complication of the exanthemata. A similar condition occasionally involves the external genitals. From the fact that it seldom passes across the middle line, it has been regarded by some as of neurotic origin. Naturally bacteria are always found in the decomposing tissues; but whether there as cause or as result is not yet established. The probability is, however, that we have to deal with a specific form of infection. The loss of substance is usually so great as to determine complete perforation of the cheek, so that the jaw bones may be laid bare. The gums and alveolar processes also frequently share in the process, and the teeth occasionally drop out. Death of tissue is rapid, and septic infection may accompany it to such an extent as to cause the death of the patient in a few days. While most vigorous measures are necessary for combating it, the patients are often so reduced as to preclude the possibility of doing much, and death is the termination of noma. Free incision, even complete excision, is called for, perhaps with combined resort to the actual cautery or such remedies as bromine (strong or diluted). Antistreptococcic serum has also been used with success. Obviously it must be used early if success is expected. Should patients recover, there is extensive deformity as the result of cicatricial contraction.

Along the coast of Africa and in the West Indies there occurs among the negroes a peculiar gangrenous affection of the toes known as _ainhum_. This may assume either the moist or the dry type of gangrene, but the result is gradual separation of the part, usually by the dry process, as if it had been strangulated by a ligature. The disease is slow and may extend over ten years. The cause is unknown.

Finally, gangrene is the termination of the infectious process in several other zymotic diseases, among the best illustrations being that afforded by _diphtheria_. The formation of diphtheritic ulcers in the mouth and the vulva, about the eyes and elsewhere, as the result of separation of sloughs, is too frequent to pass unnoticed, yet at the same time does not essentially differ from the separation of sloughs due to any other specific cause. All these acute zymotic diseases, therefore, need to be regarded as among the possible causes of gangrene by infection of tissues.

The _symmetrical gangrene_, often paroxysmal, affecting the fingers and toes, described by Raynaud and often called by his name, is due to vasomotor spasm, and is accompanied by neuralgia and sensory disturbances, with coldness of the part and discoloration suggestive of impending gangrene. (See above.)

Billroth and others have also described a _spontaneous_ or _angioneurotic gangrene_ of the extremities, occurring during youth, in abrupt distinction to senile gangrene, whose course is tedious and painful, which will usually necessitate amputation. The cause of this condition has been found to be a well-marked arteriosclerosis and thrombosis, both in the arteries and veins. This form of gangrene occurs most often in the frigid zone--_e. g._, in Northern Russia.

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.

## PART II.

SURGICAL DISEASES.

##