GANGRENE

 

 

Gangrene is defined as the gradual destruction of living tissue, due to an obstruction in the supply of blood and oxygen to an area of the body. Any part of the body can be affected by gangrene, but it most frequently occurs in the hands, fingers, feet and toes, particularly as these acral parts of the body seem to be the most susceptible to trauma.

 

Gangrene can also occur internally and is extremely dangerous if abdominal organs are involved. It does not generally discriminate between the sexes, although a predisposition to malnourished, elderly persons or those with Diabetes mellitus or serious vascular impairment is recognised. 

 

Gangrene can be divided into three categories:

1.      Dry gangrene

2.      Wet gangrene

3.      Gas gangrene

 

Although the list of contributing factors causing each type of gangrene is unlimited, some of the documented causes show whilst arteriosclerosis obliterans and thromboangitis obliterans account for 95% of all cases of PVD causing damage, additional causes of gangrene are:

 

Gangrene of the fingertips may also complicate meningitis, malaria, typhus fever, typhoid fever, diphtheria and pneumonia.  Anthrax or malignant pustule, which is characterized by a carbuncle or papule with black centre surrounded by a halo of vesicles and inflammation, may result in gangrene of the hand.  Ulceration of the fingertips has been reported following MI.

 

Smoking and excessive alcohol consumption have also been recognised as specific risk factors because of the possibility of arteriosclerosis and interference to the function of the blood vessels respectively.

 

DRY GANGRENE

Dry gangrene is caused by a gradual reduction in the blood supply to an area of tissue.  The resultant obstruction usually only involves the arterial blood supply without interference to the venous return and is a type of “coagulation necrosis”.

 

Clinical Features

Unlike wet gangrene, dry gangrene is almost exclusively limited to the extremities. In the initial stages of dry gangrene, the affected area is extremely painful to palpate. This area then becomes dry and wrinkled, with distinct colour changes occurring. The skin becomes dark brown at first and as the necrosis continues, turns a dark purplish-blue and then completely black. This process is very slow and a distinct “line of demarcation” is visible between the necrotic tissue of the gangrenous area and the surrounding healthy tissue. This line is one of the most important clinical features of dry gangrene and is the result of inflammation caused by irritation from the dead tissue.

 

Diagnosis

Good medical history and thorough examination

Tissue or blood cultures from affected site.

 

Treatment

As dry gangrene is rarely life threatening, regular monitoring of the progression of the disease is often all that is required. Eventually the area of dead tissue becomes autolytic and healing takes place at the demarcation line between the dead and living tissue.

 

 

WET GANGRENE

 

Wet gangrene is caused by a bacterial infection in an area of tissue that has been denuded of blood and oxygen.  Cells in the area surrounding the necrotizing tissue begin to lyse and release fluid.  In the presence of this moist environment, bacteria flourish. The bacteria most likely involved are Staphylococcus epidermidis, Enterobacter, Kleibsiella and Streptococcus.

Clinical Features

Where the cause of wet gangrene is the Streptococcus bacterium, there is usually evidence of infection (pain, erythema, swelling and heat), with an associated fever.  Between 36-72 hours after infection, small vesicles or yellow bullae begin to surround the area, which may appear bluish-black. These blisters (which may exude a foul smelling discharge) burst and form a black eschar, “...which sloughs in 7-10 days”.

 

Unlike dry gangrene, there is no line of demarcation between normal tissue and infected tissue in wet gangrene and the spread is rapid.

 

Diagnosis

 

Prognosis 

The spread of infection is very fast and death may occur unless the condition can be prevented from becoming systemic.

 

 

GAS GANGRENE

 

Gas gangrene is often associated or confused with wet gangrene.  But, it is an individual disease state because infection occuring in devitalized tissues is usually caused by one of the Clostridium bacteria.

 

Clostridium perfringens normally resides in the gastrointestinal tract, female genitalia and in soil.  It is an anaerobic bacterium, which can invade traumatized tissue, particularly around deep necrotic wounds.  Where infection occurs, it produces “...thrombosis of regional blood vessels, tissue necrosis and localized oedema.” A release of hydrogen and carbon dioxide subcutaneously from the necrotic tissue produces interstitial gas bubbles. Spores flourish in the anaerobic environment, which multiply and destroy cells in the surrounding tissue.

 

Clinical Features

The onset of gas gangrene occurs rapidly within 12 to 48 hours, with most clinical signs apparent within the first 72 hours post surgery or trauma. The most significant feature of gas gangrene is the audible cracking sound made by the “crepitant tissue”, which can be heard whenever the patient is moved. This is a result of the ongoing metabolic processes in the necrotic tissue.

 

Other signs include extreme pain, a low fever, ischaemia, loss of pulses, pallor, inflammation and a red or dusky brown discolouration of the area. Within 36 hours after the presentation of symptoms, a bullous eruption may occur, revealing dark red necrotic tissue, with an odorous watery discharge. Anaerobic cellulitis may occur because of blood vessel thrombosis, spreading the infection quickly.

 

As the infection progresses, the patient becomes pale and limp, exhibiting “...signs of toxemia and hypovolemia (tachycardia, tachypnea and hypotension)...”.

 

Diagnosis

Diagnosis is usually determined by the presenting clinical features and by affirming a recent history of trauma or surgery. Cultures from the wound confirm the diagnosis by recording findings of C. perfringens, with a presentation of gram positive bacillus bacteria. X-rays of the area show black spots within the tissue, synonymous with gas bubbles. Blood tests may reveal leukocytosis and hemolysis in later stages.

 

Treatment

Debridement of necrotic tissue is carried out.

 

Prognosis

In severe cases, where treatment has not been administered in time, delirium, coma and circulatory shutdown usually precede death.  Where the disease has been diagnosed in its early stages, wide debridement of the area is done.  

 

 

GANGRENE – HOMOEOPATHIC THERAPEUTICS

 

Arsenicum

SENILE GANGRENE; ulcers extremely painful or entirely insensible, with elevated edges, secreting a bad, watery foetid ichor; hard, shining, burning swelling with bluish-black, burning vesicles, filled with acrid ichor (<) from warmth, (<) from cold; extreme restlessness; gangrene accompanied by foetid diarrhoea; great weakness and emaciation; numbness, stiffness and insensibility of the feet; general coldness with parchment-like dryness of the skin, followed by heat. Dry gangrene in old people, soreness and burning relieved by warmth, restlessness. It is often indicated in gangrene of the lungs.

Arsenicum has a foetid diarrhoea, great weakness, emaciation, and coldness and heat alternately.

Secale is aggravated by warmth, thus differing from Arsenicum.

 

Carbo veg

Senile gangrene, HUMID GANGRENE IN CACHECTIC PERSONS whose vital powers are exhausted; great foulness of the secretions; great prostration; sepsis; indifference; fainting after sleep, while yet in bed, morning; no restlessness. Carbuncles and boils, becoming gangrenous. There is no restlessness, as in Arsenicum, but the parts have a livid purple look, and they are icy cold. It also suits moist gangrenous in cachectic persons whose vitality is weak. The secretions are foul and there is great prostration.

 

Crotalus horridus

Gangrene, skin separated from muscles by a foetid fluid; black spots with red areola and dark, blackish redness of adjacent tissues; sluggish circulation, low fevers, CARDIAC DEBILITY, feeble pulse, faintness, torpor of mind and quiet indifference; traumatic gangrene; old scars open again.

 

Lachesis

Gangrenous blisters, bluish or black-looking blisters; vesicles appearing here and there, increasing in size, with violent itching and burning, as if the flesh would be torn from the bones; swelling and inflammation of the part, with violent pains, dry mouth, dry skin, constant fever and thirst; tingling in the part, with heat and numbness, skin cracked and deep rhagades; coldness of the part, as if ice were in contact with it; itching pain and painful spots appearing after rubbing, with dark-blue borders and dry scurfs. GANGRENE INJURY (Crotalus has similar symptoms, which must be well differentiated.)

 

Secale cor

DRY GANGRENE of the extremities, the parts are dry, cold, hard and insensible, of a uniform black color and free from foetor. Large ecchymoses, blood-blisters on the extremities, becoming gangrenous, black, suppurating blisters. The limbs become pale, cold and shrivelled, or cold and   lead-colored, losing all sensibility; (<) from cold applications. Corresponds to senile gangrene with tingling and formication. Dry gangrene of toes; a number of cases of cure of this condition by Secale are on record. The skin is wrinkled and dry, shrivelled and cold, no sensibility, black and free from foetor. Large ecchymoses and blood blisters, which become gangrenous, will indicate the remedy.

 

Aconite

Deathly paleness of face and shuddering; the part first swells and then assumes a blackish color; sleeplessness and restlessness; chilliness from least uncovering; sweat cool in palms of hands; coldness of feet up to malleoli, with sweat on toes and soles of feet.

 

Arnica

Hard, hot and shining swelling of parts affected; gangrene follows contused wounds; thirst before fever; pain in periosteum of all the bones; pain in cartilage of ears, as if contused; swelling of nose, with feeling as if from ulceration of nostrils; tendency to boils and carbuncles.

 

Asafoetida

Dark-red and hot swellings; bright-red appearance of the wounds hich are sensitive to touch; coldness and dryness of skin with rapid pulse.

 

Aurum met

Gangrenous diseases with oedematous swelling of the parts; very sensitive to cold, (<) at night, disturbing sleep; low-spirited, with suicidal ideas.

 

Belladonna

Fiery redness of swelling, even erysipelatous; dry, hot skin, thirst and headache, erysipelatous indurated swellings which mortify, accompanied by glandular swellings; secretions of bloody ichor.

 

Bromium

HOSPITAL GANGRENE; death of the edges of the wound; cancerous ulcer in face; stony-hard swelling of glands, especially on lower jaw and throat; decayed teeth and gums; foul breath; much  prostration and emaciation; psoric constitution.

 

China

After profuse and frequently repeated haemorrhage, with coldness of the extremities or of the whole body, with pale and clammy face; the parts around the wound become soft, blue and swollen; bedsores in people who are much debilitated from excessive discharges.

 

Conium

Gangrene from contusions; glands swollen indurated; feeling of heat in the whole body; perspiration all over; depression of spirits.

 

Euphorbium

GANGRENE FOLLOWING GASTRITIS OR ENTERITIS, temperature continually falling; inflammation and swelling, followed by cold gangrene; torpor; insensibility of parts affected; chilliness and shuddering over whole body; gangrene senilis.

 

Laurocerasus

Gangrene of the penis, internally and externally, swelling of the glands of the neck; pains aggravated by hot or cold applications.

 

Mezereum

Burning of the internal parts, with external chilliness; sensitiveness to cold air; pulse full and hard.

 

Muriatic acid

Putrid gangrenous ulcers on the lower extremities; great sensitiveness to dampness; pulse weak and slow; chilliness and shuddering; oedema of the part.

 

Phosphoric acid

Senile gangrene.

 

Sulphur

Bedsores, with gnawing pains; red, shining swelling of the toes; putrid ulcers, turning to gangrenous sores; sloughing phagedaena.

 

Sulphuric acid

TRAUMATIC GANGRENE; blue spots like suggillations; bedsores; haemorrhages from wounds; dark pustules; deathly pale face; subjective sensation of trembling.