Obrázky stránek
PDF
ePub

cellular reaction. If present they are to be found some distance from the primary necrosis.

The prognosis seems to be more favorable today than before the antiseptic period. When complications are not grave and surgical measures can be promptly instituted the mortality should not be too great. The constitutional symptoms seem to be attributable to toxemia. Free incisions or amputation are the treatment promising best sucWhen the extremities were primarily affected amputation showed 68% of recoveries, whereas incisions without amputation gave only a result of 33 1-3%. Bloodgood thinks that amputation is not always necessary. When infection is recognized early and the destruction of tissues is not too extensive, free incisions with immediate continuous bath treatment should be tried.

cess.

It may not be out of place here to report a case which recently occurred in my practice.

James C., of Vickery, O., age about 15 years, was shot on March 13, 1902, in the right axillary region, touching the lower border of the pectoral muscle, and also the region of the axillary artery. There was considerable hemorrhage at the time. Dr Bowman, of Vickery, removed the shots and wad, and thoroughly disinfected the wound. About forty-eight hours later gangrene set in, small incisions were made over the affected parts in several places, and these gave exit to gas, which from that time bubbled up constantly. I saw him on March 16, about seventy hours after the accident, and found the arm black up to the shoulder-joint. The incisions, from which gas still worked out, were considerably enlarged. It felt like cutting into a moist rubber bag, the muscles looked white like boiled meat, and some bloody serum escaped, but no pus. The temperature was 102°, pulse 96 soft and full, and the patient felt well and had a fair appetite. He was never delirious. As there were some cyanotic spots over the region of the pectoral muscle, and also some puffy swelling over the scapula, I thought it might be better to wait a day or two longer for amputation, so that the line of demarkation would be more complete. On March 19 I saw him again, and found that gangrene had not extended any further, and that the blue

spots over the chest had disappeared. Before amputation I made some cover-slip preparations and some agar and blood-serum cultures. Gas and bloody serum still escaped, and the incised muscles looked black. As I was afraid that there might be thrombosis of the axillary vessels I ligated them near the clavicle, where I found them in a healthy condition. All the affected muscles were removed, and I found sufficient skin to cover the surface. The patient made an excellent recovery, although his temperature kept up to 1011° for three days. As I do not claim to be a bacteriologist, and the operation was made some distance from home, not all the requirements in regard to anaërobic culture and inoculation into animals could be fulfilled. Owing to pressure of business I also neglected to submit the specimens to Dr W. T. Howard, Jr., in proper time to make inoculation and anaerobic cultures. The examination was only made about six weeks after operation, and Dr Howard was kind enough to furnish the following report:

Examination of coverslip preparations from the arm and cultures from Dr Stamm's case of gas-phlegmon.

Two coverslip preparations from the incisions made in the arm before operation show numerous bacteria. (1) Large numbers of straight or slightly curved, long, stout bacilli, about some of which halos can be made out. The specimens were stained, one with methylene blue, one with gentian violet. No distinct capsules were seen. These bacilli, which occur singly, in pairs, or sometimes in groups, are of the size and appearance of the bacillus aërogenes capsulatus. (2) A considerable number of somewhat shorter bacilli, swollen at one end, which always shows a spore. No halo can be made out about these bacilli. They do not appear to be spore-bearing forms of the first variety described. (3) A few cocci, usually in pairs, and few leukocytes are to be seen. Coverslips from aërobic agar, potato and blood-serum cultures show, first numerous staphylococci; second, many spore-bearing bacilli, similar to those described in the preparations from the arm; third,

a few long, stout, bacilli of the size of bacillus aerogenes capsulatus. These latter were probably carried over from the inoculation and do not represent growth. The long, stout bacillus with a halo and probably a capsule, found in the coverslip preparations from the arm and in small numbers in the cultures, is in all probability bacillus aërogenes capsulatus. A positive diagnosis is, of course, impossible in the absence of anaerobic cultures and animal experiments. The history of the case and the morphologic characters of this bacillus warrant one, I think, in making a diagnosis.

Conclusions: Mixed infection of the arm with staphylococci, unknown spore-bearing bacilli, and bacilli apparently identical with bacillus aërogenes capsulatus.

I may add that the agar culture was not liquefied, but the blood-serum was liquefied and emitted a penetrating fetor, also a few gas bubbles.

DISCUSSION

Dr S. S. Thorne, Toledo: I would dislike to see so good a paper passed by without comment. I wish to congratulate Dr Stamm for his successful work along this line, because I believe that there is a consensus of opinion against operative procedure in these cases. In past years we came to the conclusion that if the patient died without an operation we were not to censure ourselves, because if we had made the operation he would have died the sooner. I have seen some of these cases, and have stood against operation, but now, as the doctor says, much can be said in favor of operation in suitable cases. An operation should not be made so long as the disease is in a progressive condition. After the progressive condition has passed there is a line of demarcation formed which is an evidence that repair has already begun to take place, and so I feel in such cases that an operation should be attempted. I was reading some reports from the Deutsche Medicinische Wochenschrift, and the consensus of opinion therein given was decidedly against operation. Of the cases reported practically every case died which had had an operation. I would like to call upon Dr Jacobson, who reported a case of this kind, with his conclusions made postmortem. I want to congratulate Dr Stamm most heart

ily on his work along this line, for it is only in work of this nature that progress is made.

Dr Julius H. Jacobson, Toledo: I rise partly as a vindication of myself from one of the remarks which Dr Thorne has made, and partly in order that such a valuable contribution may not go by without some discussion. I have had some experience with the bacterium spoken of by Dr Stamm as I have made some experiments along this line myself. The case from which I got the cultures and made the experiments was not one where the diagnosis was arrived at at postmortem as Dr Thorne has stated, but antemortem. I did not have the fortune to have a recovery in my case such as Dr Stamm has reported, but it was one from which much could be learned. I believe that these cases occur more frequently than we would ordinarily suppose but they are not recognized. A great many of the older surgeons will remember cases of emphysematous gangrene in which the odor was said to be due to the decomposition of tissue, or the entrance of air into the tissues. We now know this to be false, that such conditions are due to the entrance of the germ erogenes capsulatus. This is a very important subject and the dissemination of the knowledge concerning it is very apt to lead to a more frequent recognition of the affection in the future.

My case occurred after a compound fracture of the forearm with rapid infection by this germ following the injury, and death ensuing later. The present consensus of opinion tends more to amputation than incision and drainage, although incision and drainage has been followed by good results.

Dr Martin Stamm, Fremont, closing: I think if I can claim any credit for the recovery of the patient it was probably due to incision rather than amputation, and I think the way in which incision was beneficial was this, viz., the bacillus erogenes capsulatus is an anarobic bacillus and the admission of air to the muscles and tissues may have had a beneficial effect in destroying or arresting the pernicious work of the bacillus. This may have prolonged the life of the patient so we could wait for the formation of the line of demarcation. After this amputation was plainly indicated and promises a fair result. I wish to thank the gentlemen for their discussion of the paper.

A Simple Method for the Removal of External Hemorrhoids Under Local Anesthesia

BY THOS. CHAS. MARTIN, M. D., Cleveland

President of the American Proctologic Society

Operation under local anesthesia is a surgical refinement which requires of the operator the highest degree of skill. The operator whose work is uniformly painless is one who is ever attentive to the minutest detail, and, I may add, also is one who adroitly manages his patient. If there be escape of blood during the operation under infiltrationanesthesia, there can be an escape of the injected anesthetic solution, also, and consequently there will be pain. Often one sees a growth dissected away without pain being provoked, but is shocked to behold the suffering inflicted by the insertion of the sutures.

The sutures should be passed before the incision is made.

It has been my custom for the past three years to operate for external hemorrhoids, cutaneous piles, condylomas, lipomas and other nonmalignant growths at or near the external anus as follows:

Two hypodermic syringes are used. The finest needles with long oblique points are employed. A 1/10 of 1% solution of eucain is prepared in a normal salt solution, which is administered at a temperature of about 98° F.

Two syringes are employed that I may not be compelled to await the loading of the first one a second time. This serves to shorten the time required for the operation in two ways, (1) the actual time required for the loading and (2) by reason of the prompt completion of the infiltration, diffusion of the artificially induced edema is prevented.

The finer the needle the more smoothly and painlessly may it be made to enter the tissues. A 1/10 of 1% solution of eucain is, in the quantities required for the operation under consideration, practically nontoxic. It may be sterilized by boiling. A saline solution is nonirritating. A warm solution does not unpleasantly affect the patient as may a cold one.

The integument in the proposed line of incision should be rendered uniformly edematous by the injection, as also

« PředchozíPokračovat »