GANGRENE.
On the first signs of threatening gangrene in a patient wearing tight bandages, splints, &c., the restrictions should be immediately removed, the limb slightly elevated and enveloped in warm, dry, antiseptic, absorbent wool. The same measures should be followed in the gangrene caused by Carbolic lotions.
When the senile form of gangrene is feared, much may be done to prevent, the death of the toes or portions of the feet by keeping the lower extremities warm and the foot free from all pressure by tight boots. Thick woollen night-socks should be worn, and hot-water bottles avoided, any threatening symptoms being met by rest in bed with elevation of the limb and warm wool coverings.
When very local or circumscribed in extent and superficial in position, as in slight degrees of traumatic gangrene, the sloughs may be hastened in the separation process by the application of moist warmth as charcoal poultices or warm boric compresses. But the surgeon should aim in all cases of gangrene at asepsis when possible. A dry gangrene becomes rapidly changed into a moist one as soon as bacterial organisms are ad mitted; therefore, sterilisation of the skin by an antiseptic should be a routine precaution before elevating the part and enveloping it in warm antiseptic absorbent wool under a light bandage pending the decision upon operative procedures.
As a rule, in gangrene of the senile type involving the feet or legs, as soon as the death of the part is obvious and the pulsation has disappeared in the posterior tibial artery at the ankle, amputation should be decided upon without delay. To wait for a well-marked line of demarcation is only to submit the patient to the dangers of an exhaustive septic inflam mation. Amputation should therefore he resorted to immediately, the incisions being made high up and well above the dead area, and in all cases above the level of the knee-joint, the lower third of the thigh being now the recognised site for removal of the dead limb, because the upper part of the posterior tibial artery or the lower portion of the popliteal is nearly always blocked.
In diabetic gangrene there is usually less urgency. The limb should be disinfected, dusted with lodoform powder, and enveloped in dry wool, and if the gangrene shows no signs of spreading the toes may be removed and the stumps dressed after a line of well-marked demarcation has formed. If, however, pulsation has already disappeared in the posterior tibial, amputation above the knee should be resorted to without further delay.
Diabetic dietary should follow up the operative procedure, but the diet should not be too restricted owing to the danger of coma. On account of this latter danger some surgeons prefer to operate under spinal anws thesia. Opium is, however, not contra-indicated in the after-treatment or at the onset when pain is prominent.
.hoist spreading gangrene is always due to the admission into the tissues of some septic organisms ; these may be present when the skin wound is trivial or when severe trauma has injured the soft parts, with contamina, tion from earth or dirt of any kind. As soon as the true septic or infective nature of the gangrene has become obvious, the only hope of saving life lies in immediate amputation performed high up, the incisions being carried through the healthy tissues, care being taken to prevent infection of the surgical wound by the secretions from the affected area. The allied condition known as _Malignant CEdema will require the same prompt and radical treatment.
In traumatic gangrene without infection the condition is akin to that which sometimes follows the ligature of a main vessel, and operative procedure may usually be safely delayed till after the shock of the accident has passed away, so that the result of the natural attempt at restoration through the anastomosing vessels may be determined. Even here it will be unwise to wait too long owing to the danger of the dry type becoming changed into a moist spreading gangrene even when there is no skin wound. When there is extensive destruction of the tissues as in com pound fracture caused by crushing machinery, &c., followed by rupture of vessels and great extrayasation of blood, the injury being certain to end in the death of the limb, amputation should be performed as soon as the first serious symptoms of shock have passed away.
In the senile, diabetic and traumatic types of the disease. when both legs or arms are involved at the same time, there is little hope to be expected from operative or other measures, but one limb should be immediately amputated so as to permit the patient to recover from the shock of the operation, when after an interval of several days the second operation may be carried out, the gangrenous limb being in the meantime subjected to rigorous antiseptic treatment.
The treatment of gangrene of the Lung, of Raynaucrs Disease, Cancrum Oris, Bedsores, Frost-Bite, Sc., is described under the heading of each affection.