Sunday, February 23, 2014

Gangrene

by Janet King, RN, BSN, CCRN.


Gangrene [Hospital gangrene; Moist gangrene; Dry gangrene; Mortification]:Civil War surgeons were often indiscriminate in categorizing the patients who had gangrene. Some stuck with the term they were most familiar with, so determining how many cases of gangrene, and of what type, is difficult. Today's doctors classify gangrene into 3 main types. The following examples are those which occurred during the Civil War, although the doctors of that era did not know the precise cause.

Moist Gangrene: This results from the loss of blood circulation due to a sudden stoppage of blood flow - i.e. accident that destroys tissue (cannon ball or bullet wound); blood clot; tourniquet that was left on too long. At first the wound tissue looks like a bad bruise, is swollen and perhaps blistered. Later as the disease progresses the tissue is destroyed and the gangrene spreads rapidly and toxins are formed and absorbed into the general circulation.

Dry Gangrene: This occurs more gradually as blood flow is slowly reduced through the arteries. The tissue of the affected part gradually shrinks, becomes cold and without a pulse.

Gas Gangrene: Although the surgeons of the 1860's did not know the cause of this type of gangrene, they surely saw the results. Most likely they classified what they saw into the other types of gangrene. This condition occurs in wounds infected by a bacterium (clostridium) and is often attributed to dirty, lacerated wounds in which the deeper tissues of muscle and fat become filled with gas and a bloody-serous fluid fills the wound. The bacteria eat away the tissue and produce toxins. This type of wound would have been produced by such mechanisms as pieces of shell, deep sabre wounds or deep bullet wounds.

Hospital Gangrene: This form of gangrene is now considered "extinct." There is no agreement to its nature, though some feel it was some type of bacterial infection, perhaps streptococcus. The effects, as seen by the surgeons and soldiers of the 1860's were devastating and deadly. "The patient might see a black spot the size of a dime appear on a healing wound, and watch with horrified interest it's rapid spread until his whole leg or arm was but a rotten, evil-smelling mass of dead flesh."

1860's Treatments: Some hospitals made efforts to isolate gangrene cases, as it had been noted to be "contagious and infectious." Surgeons tried various drugs in a "conservative" approach at treatment. These included the use of bromine, considered one of the "miracle drugs." The patient was given ether or chloroform as an anesthetic; the diseased and sloughing tissue would be clipped and cut out until the wound was as clean as possible. Then pure bromine (a very costive agent!) would be applied beneath the edges of the wound. Lint moistened with a weak solution of bromine would be used to fill up the entire cavity or ulcer. Sometime "miraculous" results occurred and the patient was saved from amputation or further treatment. Other drugs used included: nitric acid, creosote, poultices of cinchona, ginger and flaxseed and various nutrients and stimulants.

Modern Knowledge:Today the specific cause of gangrene would be determined. If the problem required surgical intervention to remove a clot or bypass the blocked blood vessels this would be done. Wounds would be tested to determine what bacteria was causing the infection and antibiotics would be given accordingly. Removal of dead tissue, and as a last resort - amputation, would be performed if needed.

From: vermontcivilwar.org

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