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Papers for the original department must be contributed ex- pound fractures and gunshot wounds of the clusively to th's magazine, and should be in hand at least one month in advance French and German articles will be trans limbs are especially liable to be followed by lated free of charge, if accepted.
A liberal number of extra copies will be furnished authors, and this form of gangrene. Of course, the path. reprints may be obtained at cost, if request accompanies the ogenic organism is also necessary, but exproof.
Engravings from photographs or pen drawings will be fur perimenters have found considerable diffi. nished when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this purpose.
culty in insolating this germ, and making
it fulfill all the postulates of Koch. The COLLABORATORS. ALBERT ABRAMS, M. D., San Francisco.
organism known as the “vibrion septique"
of Pasteur, and called by others the bacillus CHARLES W. BURR, M. D., Philadelphia.
of malignant edema, was formerly thought C. G. CHADDOCK, M. D., St. Louis, Mo.
to be the real cause of this trouble, but in S. SOLIS COHEN, M. D., Philadelphia, Pa. ARCHIBALD CHURCH, M. D., Chicago.
1891, Welob discovered that this form of N. S. DAVIS, M. D., Chicago. ARTHUR R EDWARDS, M. D., Chicago, Ill.
gangrene was nearly always associated with FRANK R. FRY, M. D., St. Louis. Mr. REGINALD HARRISON, London, England.
an organism known as the bacillus aerogenes RICHARD T. HEWLETT, M. D., London, England.
capsulates; he found that if guinea-pigs were HOBART A. HARÉ, M. D., Philadelphia.
injected with fresh cultures of this bacillus, CHARLES JEWETT, M. B., Brooklyn.
looal gangrene with emphysema and even THOMAS LINN, M. D., Nice, France. FRANKLIN H. MARTIN, M. D., Chicago.
death resulted; rabbits and mice were found E. E. MONTGOMERY, M. D., Philadelphia. NICHOLAS SENN, M. D., Chicago.
to have greater resistance, and generally with. FERD C. VALENTINE, M. D., New York.
stood its invasion; however, when rabbits EDWIN WALKER, M. D., Evansville, Ind. REYNOLD W. WILCOX, M. D., New York.
with broken bones were injeoted intraven. H. M. WHELPLEY, M. D., St. Louis. WM. H. WILDER, M. D., Chicago, Ill.
ously gaseous abscesses formed around the ends of the fragments, and when such ani.
mals were killed, and their bodies kept in LEADING ARTICLES
warm surroundings, they soon underwent
rapid gaseous degeneration. This probably FOUDROYANT GANGRENE.*
explains wby this variety of gangrene travels so rapidly, especially when hot external ap
plications are applied to the parts affected. W. H. WILDER, M. D. .
Recently Iacobelli bas insolated a bacillus BIRMINGHAM, ALA.
in two cases of gaseous gangrene, which is President Tri-State Medical Society of Alabama, Georgia very similar to that found by Legros, and
called by the latter the "septic aerobic bao. My object in presenting this brief paper illus." Iacobelli does not consider his bacis to report two cases of this fearful malady illus identical with that of Woloh; guinea that came under my care last year, and to try pigs inoculated with pus from gangrenous to bring out sopie discussion of that most wounds caused by this bacillus died in about virulent form of gangrene, which is so rapid twenty-four hours, but did not show any gas. in action, so fatal to life and limb, and which eous gangrene. It was also found to be very is known by so many names in our literature, resistant to antiseptics. The natural habitat such as 'spreading traumatic gangrene," of the micro-organisms seems to be in the "malignant edema," "purulent edema,”. soil and in the alimentary canal. Combined "fulminating gangrene," "emphysematous with the bacilli above mentioned streptogangrene," "gangrenous emphysema,"'ga'n coooi have nearly always been found in this grene foudroyante'' (French), etc., I prefer variety of the disease in man. to anglioise tbe latter term and call it foud. When the edema begins the blood vessels royant gangrene.
are compressed and sometimes occluded, and In this form of gangrene there must be an this materially lowers the vitality of the part open wound, a restricted or occluded arterial and gives impetus to the disease. This form or venous blood supply and a septic infection. of gangrene usually appears within two or The ipjury necessary may vary from a small three days after the patient has received a scratch to a large and severe laceration, such severe laceration, contusion, gunshot or as we so frequently meet with in dealing with some other wound which cannot be or has those who have been hurt by machinery or in not been thoroughly disinfected. In some railway injuries. Crushed injuries, onm. cases there are irregular chills followed by
more or less fover, just as may be seen in any Read before the Tri-State Medical Society, Chatta
form of sepsis; in other cases these chills
and Tennessee, 1903.
nooga, Tenn., September 26, 191'5.
may be absent and the fever may not be rapid advances of the disease are pathog. marked until after the patient has become nomcnic. The early recognition of the dis. overwhelmed with the septic ptomaines. The ease is quite essential to its successful treatpulse, which at first is not much quiokened, ment. Death is the usual result in from 70 increases in rapidity and decreases in volume to 80 per cent of all patients so afflicted, and as the fover rises; the respirations are shallow more than 90 per cent of those who do not and rapid; the urine shows an increasing die are compelled to undergo bigh amputaamount of albumin, nausea and vomiting sets tion of the affected limbs to save life. Sta. in, the patient has a very anxious expression tistics on this form of the disease are scarce. of countenance, his face becomes pale, he C. P. Gildersleeve (Medical Record, March grows very restless, delirium appears, and in 4, 1899) reports a series of sixteen cases in short he has all the symptoms of acute viru. which the bacillus aerogenes capsulatus was lent sepsis. Pain in the injured part is fre found; there were twelve deaths, a mortality quently not severe at first, but as the disease of 75 per cent. This may be considered an advances and the affected part becomes more average mortality in this frightful malady, and more edematous, it increases and becomes even since the time of antiseptics, since quite excruciating. Soon after receiving the which time the disease is not so frequent as injury a slight edema appoars, and the skin formerly; therefore, prophylaxis by means of changes its color to a dusky brown bue, thorough surgical cleanliness is the first in. somewbat the color of a rind of bacon, due dication in treatment. All authors advise to the extravasated hemoglobin, and there are prompt and high amputations above the edestreaks of a dark greenish yellow color extend. matous zone as soon as the disease is recog. ing up the limb. The rapidity with which nized; the arm should be taken off at or these obanges takes place is a marked charac. near the shoulder joint and the lower extrem. teristic of this disease; it travels bour by ity high up in the thigh. We should always hour and within a day or two from its onset go high enough, if possible, to avoid tissues bas involved the whole limb. The swelling that are swollen and filled with the greenish increases rapidly and blebs or bullae filled brown serum above alluded to. No sutures with a dark straw colored fluid form beneath whatever should be put in the flaps, which the epidermis, and the superficial veins of the are to be left wide open to be dressed at fre. limb, especially those on the inner side, stand quent intervals with hot antiseptic (prefera. out in bold relief, showing a very distinct bly biobluride) solutions until the soft tis. and irregular smoky greenish color of the sues become healthy. It is needless to state skin between them; gaseous emphysema that such operations should be done with caused by putrefactive bacteria appears and dispatch, and everything done to sustain the gives a crackling feeling to the tissues be patient already overwhelmed with septic ptoneath the skin; putrefaction advances rapid.. maines. Dr. Van Buren Knott (Jour. A. ly along the lymphatics, the tendon sheathes M. A., April 11, 1903) practices somewhat a the connective tissue spaces and beneath the novel procedure in these cases; he estimates fasciae, and if not promptly arrested by as nearly as possible the line between the bigh amputation these chemioal poisons get healthy and diseased tissues, and after thor. into the patient's general circulation, and he oughly cleansing the limb and wrapping the soon dies from the invasion of the septic gangrenous parts in sterile towels, amputates ptomaines.
. circulary all the soft tissues and bone at the In this form of gangrene, nature seems to same level, taking particular care to ligate be utterly unable to cope with the invading every bleeding vessel without including any poison, therefore no line of demarcation is perivascular tissue in the bite of the forceps perceivable, and to wait for its appearance is or ligature. The wound is left absolutely to invite death. The wound is usually of an open-not using a single suture—and dressed asben gray indolent appearance with no ten. with gauze saturated in hot saline solution, depoy to heal, and if the limb be out into a which dressings are changed from two to four greenish purulent serum, with no tendency times a day. After a week or ten days if to localization comes from every direction. the wound is clean, and the patient's condi. It is a mistake to think that gangrenous parts tion is good the flaps, already outlined, are do not bleed freely when incised.
dissected up, the remaining soft tissues cut, The diagnosis of this form of gangrene and the bone sa wed off at the proper level, is usually not very hard to make, especially The advantages claimed for this procedure in its advanced stages. Some or all of the are that the gangrenous tissues are speedily above symptoms outlined are easily recog. removed from the enfeebled patient rapidly nized; the crackling of the skin on palpation, and with little shock, free drainage is prothe dusky brown bue to the integument with vided, allowing an interval in which to no line of demarcation apparent, and the build up the patient, and the limb is ampu
may annous Lerwardee incisos in
tated at the lowest point consistent with tion was given intravenously just at the close safety. I have never tried this method, but of the operation; patient's condition was so it seems rational and worthy of considera. bad he died at 6:00 p.m., just forty-five hours tion. In a few early cases in which the in. after his admission to the hospital, and six fection is limited free incisions of the afflicted hours after operation. part and afterwards keeping the limb in a continuous hot boric acid or saline, both
CASE II.-W. M. D., male, age 47, a rail. may arrest the disease; but we should be al.
road brakeman, fell from the top of a box. ways on the lookout and ready to amputate
car on June 30, 1904, about 11 o'clock p.m.,
and sustained a compound fracture of the promptly. A few hours delay in this form
left radius, near the wrist. He was admitted of gangrene may mean the loss of a life. After operation, we should, of course, ba very
to St. Vincent's Hospital at 6 o'clook careful to stimulate the patient with alcohol
next morning, July 1st; put under chloroand strychnine, provide good nourishment
form, wound examined and as thoroughly as soon as he is able to take it, and above
cleansed as possible, and dressed antisepti. all see that the stump of the limb is dressed
cally on a splint. The circulation in the often so as to keep it clean and provide as
hand was good and he did very well until
the fifth day, when evidences of sepsis set in free diainage as possible. My two cases were are follows:
about the hand, wbioh was freely incised
and dressed in hot bichloride gauze; on the CASE I.-W. P., male, age 35, foreman of
morning of the sixth day the hand looked a a railroad construction gang, on Maroh 29,
little better, but during the next twenty-four 1904, dropped a pistol from his pocket, and
hours bis pulse ran up to 116 and the tem. the fall caused the weapon to explode, the
perature to 104 deg. F. The skin on the ball entering the fleshy part of the calf of
arm now began to show the dusky brown the rigbt leg on the inner side four inches
color which was spreading rapidly toward below the knee, passing through the limb
the shoulder, crepitation in the cellular tis. bebind the bones which were not injured,
sues could be felt, the patient was Aighty, and coming out two inches bigher on the
and gangrene was evident. I advised im. outer surface. The patient, not believing
mediate amputation, but patient's wife dethat his injuries were dangerous, remanied
sired to wait until her family physician, Dr. in bis car out on the road two days and con.
John A. Moore, could see her husband. The tinued to superintend the work from his
consultation was held four bours later, durbunk; at the end of that time he came to
ing which time patient had grown rapidly St. Vincent's Hospital and was admitted at
worse, and at 1 p. m., July 7, 1904, I ampu9 p.m., on March 31.
tated the arm near the shoulder. Patient His condition was fairly.good with a tem.
was under the ether just fifteen minutes and perature of 99 deg. and a pulse of 96. The
1000 c.c. of hot normal salt solution was wounds of entrance and exit looked healthy,
given suboutaneously during the operation. the circulation in the part was good, there
The stump was left wide open, and dressed was very little swelling of the limb, but pa
with hot biobloride gauze, which was tient complained of great pain in the leg. His
obanged twice daily for ten days. His coninjuries were dressed antiseptically and pa.
dition was very precarious for two or three tient put to bed with instructions to night
days after which he began to show some nurse to give a quarter of a grain of mor.
signs of improvement. About this time a phine hypodermically to ease pain. He bad
large pectoral abscess, caused from the salt à fairly good night, but next morning the
solutirn, developed and complicated matters limb was more swollen and circulation was
considerably, this was opened with cocaine not so good, pulse and temperature about
anesthesia, and after a long and stormy con.
valescence he made a good recovery. same as evening before. Hot applications were applied and frequently changed for
2218 7th avenue. the next twenty-four hours, at the end of which time the pain had increased, pulse gone NASAL PAPILLOMA.—Stenosis is generally to 120 and temperature to 102 deg. F., and moderate, the discharge slight and hemormarked gangrene had made its appearance. rhage occasional. The disease appears as I advised immediate amputation. Patient's small, warty growths, near the margin of mother declined this until her family phy. the nostril. When farther back (always sician, Dr. E. M. Robinson, saw him. It arising from lower turbinate), they are was three hours before the consultation was larger, softer and somewhat pendulous, with held, at the end of which the thigh was am a bright pink, raspberry surface. One putated rapidly at the junction of the middle should remove the swelling with a cold wire and opper third; 1000 c.o. of hot saline solu. snare, then cauterize with the galvanocautery,
was circulation ince and extra 30
there applicaning before, temperatu