Surgery, a practical treatise with special reference to treatment / by C.W. Mansell Moullin ; assisted by various writers on special subjects.
- Mansell-Moullin, C. W. (Charles William), 1851-1940.
- Date:
- 1893
Licence: Public Domain Mark
Credit: Surgery, a practical treatise with special reference to treatment / by C.W. Mansell Moullin ; assisted by various writers on special subjects. Source: Wellcome Collection.
Provider: This material has been provided by the Augustus C. Long Health Sciences Library at Columbia University and Columbia University Libraries/Information Services, through the Medical Heritage Library. The original may be consulted at the the Augustus C. Long Health Sciences Library at Columbia University and Columbia University.
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![are tlie result of the ordinary germs, acting under conditions peculiarly favorable to them : overcrowding, for instance, and poisoning by foul air, in the case of hospital gangrene ; and syphilis in the case of phageda^na. The simplest examjjle of moist gangrene is seen in a lacerated wound. A portion of the tissue is killed, it remains for two or three days adherent to the surface, slowly changing color, and then cpiietly drops off, detached from the part that is living by the vascular lymi)h thrown out. If it is very tough and hard— tendon, for example, or bone—so that the blood-vessels are scanty and unable to dilate, the process may take weeks instead of days. Bed-sores, due partly to pressure, partly to the irritation of urine and retained ])erspiration, are examples on a larger scale. The skin at first is reddened, then fluid collects beneath the epidermis; this gives way, exposing the corium ; and the continued irritation and pressure combined soon cause it to slough. Decom- position sets in, and the poison so formed, added to the already existing causes, kills the tissues round until a part is reached where the vitality and power of resistance are sufficiently good. Nearly all forms of gangrene that are dry at first end in this way. Even if the centre remains hard and resists putrefaction, suppuration occurs around the margin, and the pus provides a sufficient amount of fluid for putrefaction. For- tunately, as a rule, by the time this has happened the tissues around the slough have recovered themselves, and have erected a barrier of young and vascular granulation-tissue, which may lose its surface as pus, but nothing deeper. When a limb is run over and crushed, or when a large artery gives way sub- cutaneously and cuts off the circulation by the pressure it causes {local traumatic goTigrejic), the changes are the same at first. Immediately after the accident the limb is cold and loses its sensibility, the skin is even whiter than natural, and is stretched and tense from the extravasation beneath, and the pulse cannot be felt. Then the color gradually becomes dusky and livid, especially toward the lower part, to which the blood gravitates; purple and green patches make their appear- ance ; bullae form, filled with a reddish fluid ; the epidermis is detached from the corium beneath ; emphysematous crackling can be felt here and there, and the odor is most offensive. The subsequent course, whether the gangrene remains local or begins to spread, depends upon the power of resistance of the tissues that are .still living, to the combined irritants. If the size of the slough is small, the tension low, and the condition of nutrition good, the tissues soon protect themselves, and a line of demarcation gradually forms. If, on the other hand, the part involved is large, such as a limb, and the tension in it is high, the products of decomposition, unable to escape, spread into all the cellular spaces in the living structures near, and stream into the lymphatics, poisoning everything they touch, and causing intense inflammation. The local traumatic gangrene, assisted by decomposition, has begun to spread. The worst example of spreadiiig traumatic gangrene met with at the present day is that which sometimes occurs after compound (open) fractures, especially those due to direct violence. There is everything to favor its occurrence and its exten- sion ; an enormous extravasation at a high temperature ; a wound, so that decom- position can begin at once; the opening usually valvular, so that the tension from the hypergemia that follows must be high ; fractured, and often dead, bone, which in some particular way is exceedingly favorable to decomposition ; and all the cellular spaces in the tissues round widely open still, with no protecting barrier of lymph. Under conditions such as these it is no wonder that, if septic decompo- sition occurs, and the products are not allowed to escape, spreading traumatic gangrene of the worst description follows. The part swells more and more ; the skin is tense, red, and burning hot; the loose cellular tissue on the inner side of the limb and along the great vessels is boggy and oedematous, filled with a sero- purulent fluid which rapidly decomi^oses and causes emphysematous crackling ; the redness keeps spreading farther and farther, round the seat of injury it gradually](https://iiif.wellcomecollection.org/image/b21213744_0073.jp2/full/800%2C/0/default.jpg)
